When performing an abdominal assessment on a client, what action should the nurse take first?

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Question 1 of 5

When performing an abdominal assessment on a client, what action should the nurse take first?

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.

Question 2 of 5

A healthcare provider is preparing to perform a routine abdominal assessment. What action should the healthcare provider take first?

Correct Answer: A

Rationale: The correct first action in a routine abdominal assessment is to inspect the abdomen. This allows the healthcare provider to visually assess for any visible abnormalities such as scars, distention, or masses. Auscultating bowel sounds comes after inspection as the second step to assess bowel motility. Palpation and percussion follow in the sequence of a comprehensive abdominal assessment. Therefore, inspecting the abdomen is the priority to gather initial information before proceeding with further assessment techniques.

Question 3 of 5

A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?

Correct Answer: A

Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.

Question 4 of 5

A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

Correct Answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

Question 5 of 5

A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?

Correct Answer: B

Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.

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