The nurse is preparing to assess the patient's abdomen. Nursing care is appropriate if which maneuver is seen?
a. The abdomen is auscultated after percus-sion.
b. The nurse instructs the patient to extend the legs.
c. The nurse inspects the abdomen before auscultation.
d. The assessment begins with palpation, followed by auscultation.
C
For an abdominal assessment, the nurse begins with inspection followed by auscultation to pre-vent accidental stimulation of movement, potentially leading to inaccurate assessment data. With inspection the nurse observes the abdominal surface for movement, scars, and pulsations; then he or she auscultates bowel sounds before potentially stimulating the bowels with palpation or per-cussion. The nurse has the patient bend at the knees to relax the abdominal wall, making abdo-minal palpation easier. Palpation never precedes auscultation of the abdomen.
You might also like to view...
A client has difficulty sleeping. Which of these methods should a nurse recommend the client try at bedtime?
a. vigorous exercise c. life review b. take an over-the-counter sleep aid d. deep breathing
What do Theory X assumptions hold?
A) Putting forth effort is natural. B) Workers are diligent, responsible, and helpful. C) Workers are lazy, uncreative, and indifferent toward work. D) Increased rewards will motivate workers.
When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is which of the following?
A) Legal representation to care B) Conveyance of information C) Assisting in organization of care D) Noting the client's response to interventions
A client diagnosed with asthma is receiving instructions about the use of albuterol. The client should be aware that albuterol may cause:
1. bradycardia. 2. drowsiness. 3. nasal congestion. 4. nervousness.