Question 1: When performing an abdominal assessment, the nurse
uses a
(see full question) different order of techniques than with other systems.
Which of thefollowing represents this order
You selected: Inspection, auscultation, percussion, palpation
Correct
Explanation: In an abdominal assessment, start with inspection,ÂÂ
then auscultation, percussion, and palpation. This isÂÂ
the preferred approach because palpation and
percussion before auscultationmay alter the soundsÂÂ
heard. (less)
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed.ÂÂ
Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2015, Chapter25: Health
Assessment, p. 658.
Chapter 25: Health Assessment - Page 658
Question 2: The nurse in post-anesthesia recovery (PAR) is caring for
a 27-
(see full question) year-old client following an appendectomy. TwentyÂÂ
minutes after receiving 4 mg of intravenous (IV)
morphine for abdominal pain, theclient continues toÂÂ
report abdominal discomfort and requests more
morphine. Which action by the nurse is best?
You selected: Observe the abdomen for distention and rigidity.
Correct
Explanation: Continued abdominal pain after administration of IVÂÂ
morphine is an unexpected occurrence and requiresÂÂ
further assessment by the nurse to rule out peritonitisÂÂ
or internal bleeding by observing the abdomen forÂÂ
distention and rigidity. Administration of more
morphine could mask the cause of the abdominal painÂÂ
and delay diagnosis of a possible postoperativeÂÂ
complication. Applying heat tothe abdomen wouldÂÂ
increase blood flow to the area and potentially increaseÂÂ
pain or internal bleeding. Positioning the client in aÂÂ
knees-flexed position may relieve the discomfort, but anÂÂ
assessment is needed before any intervention is
implemented.