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A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Palpate the abdomen before auscultation
- B. Inspect the abdomen after palpation
- C. Auscultate before palpation
- D. Start by percussing the abdomen
Correct Answer: C
Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.
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A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?
- A. Increased bowel sounds
- B. Nausea
- C. Elevated blood pressure
- D. Fever
Correct Answer: B
Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.
A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?
- A. Improved mobility
- B. Bowel inflammation
- C. Long-term use of the medication
- D. Frequent dehydration
Correct Answer: B
Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.
A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?
- A. Crush medications and mix them with honey
- B. Provide medications through a straw
- C. Place the medications in small amounts of pudding
- D. Offer the medications with a full glass of water
Correct Answer: C
Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.
A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?
- A. Reassure the client of the surgeon's skill
- B. The surgeon will answer your questions before surgery
- C. Tell the client surgery is necessary
- D. Encourage the client to seek a second opinion
Correct Answer: B
Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.
When performing an abdominal assessment on a client, what action should the nurse take first?
- A. Palpate the abdomen
- B. Auscultate bowel sounds
- C. Inspect the abdomen
- D. Percuss the abdomen
Correct Answer: B
Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.