Nokea
The nurse is preparing to perform a patient's abdominal assessment. What examination sequence should the nurse follow?
- A. Inspection, auscultation, percussion, and palpation
- B. Inspection, palpation, auscultation, and percussion
- C. Inspection, percussion, palpation, and auscultation
- D. Inspection, palpation, percussion, and auscultation
Correct Answer: A
Rationale: When performing a focused assessment of the patient's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation.
You may also like to solve these questions
A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?
- A. Muscle wasting
- B. Chronic jaundice in the absence of liver disease
- C. The presence of fat in the patient's stool
- D. Persistently low hemoglobin and hematocrit
Correct Answer: D
Rationale: In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results. This would result in a marked reduction in hemoglobin and hematocrit.
An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?
- A. Percussion
- B. Auscultation
- C. Inspection
- D. Rectal examination
Correct Answer: A
Rationale: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.
The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test?
- A. In a knee-chest position (lithotomy position)
- B. Lying prone with legs drawn toward the chest
- C. Lying on the left side with legs drawn toward the chest
- D. In a prone position with two pillows elevating the buttocks
Correct Answer: C
Rationale: For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A knee-chest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.
A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?
- A. Diet high in red meat
- B. Upper GI bleed
- C. Hemorrhoids
- D. Use of iron supplements
Correct Answer: C
Rationale: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.
A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect?
- A. The patient's BUN and creatinine levels are within reference range following the CT.
- B. The CT yields high-quality images.
- C. The patient's electrolytes are stable in the 48 hours following the CT.
- D. The patient's intake and output are in balance on the day after the CT.
Correct Answer: A
Rationale: Both sodium bicarbonate and Mucomyst are free radical scavengers that sequester the contrast byproducts that are destructive to renal cells. Kidney damage would be evident by increased BUN and creatinine levels. These medications are unrelated to electrolyte or fluid balance and they play no role in the results of the CT.