Correct Answer: A,B,C,D,E

Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.

Correct Answer: A,B,C,D,E

Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.

Correct Answer: B,C,D

Rationale: When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors. At the client's bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the 'three checks' process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors. Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the 'three checks' and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen. While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the 'three checks' and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection. When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.

Correct Answer: D

Rationale: Informing the provider is important but not the first step; the immediate priority is ensuring the client’s safety for surgery. Documenting the incident is necessary but secondary to addressing the clinical need. Preparing an incident report is for quality improvement and not the immediate action. Obtaining the client's type and cross-match is the first action to ensure compatible blood is available for surgery, directly addressing the oversight.

Correct Answer: C

Rationale: Edema and distended neck veins indicate fluid overload, not deficit. Postural hypotension occurs due to reduced blood volume, causing dizziness upon standing. Tachycardia, not bradycardia, is expected as a compensatory response to fluid loss.