Nokea
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
You may also like to solve these questions
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
- A. Preventing addiction
- B. Alleviating pain
- C. Facilitating mobility
- D. Preventing nausea
Correct Answer: B
Rationale: The primary goal of opiate analgesics like Percocet is to alleviate pain, improving comfort and recovery post-surgery.
A 34-year-old client is receiving an IM injection of ceftriaxone (Rocephin) for a urinary tract infection. Which is correct regarding IM injections?
- A. A 1-inch-long 25-gauge needle should be used.
- B. The injection should be given at a 45-degree angle.
- C. The injection should be given at a 90-degree angle.
- D. A bleb should form on the skin's surface following injection.
Correct Answer: C
Rationale: IM injections are given at a 90-degree angle to ensure muscle penetration. A 25-gauge needle is too small, a 45-degree angle is for subcutaneous injections, and a bleb indicates intradermal injection.
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
- A. Notifying the doctor immediately
- B. Documenting the finding in the chart
- C. Decreasing the rate of IV fluids
- D. Administering vasopressive medication
Correct Answer: A
Rationale: Increased dilute urine suggests diabetes insipidus, a complication of pituitary surgery, requiring immediate physician notification for evaluation and treatment.
A client must take oral potassium supplements every day. The nurse explains to the client that the potassium supplements
- A. need to be stored in the refrigerator.
- B. should only be taken in the evening before bed.
- C. should be diluted in a glass of cold water or juice.
- D. need to be taken on an empty stomach.
Correct Answer: C
Rationale: Oral potassium supplements should be diluted in water or juice to reduce gastric irritation and improve absorption.