Assessing abdomen Flashcards
The nurse is about to begin a focused abdominal assessment on a client that is scheduled for surgery tomorrow. What primary nursing action should be done prior to the physical assessment?
Request that the client try to empty the bladder.
Rationale:The nurse should ask the client to empty the bladder prior to assessment to avoid discomfort or pressure during the physical examination. Auscultating for bowel sounds is part of the actual physical assessment. The ileocecal valve is the area where bowel sounds are most often heard. The client should be placed in a supine position for physical assessment of the abdomen, lateral Sims is used for enema insertion. A drape or blanket should not be removed, but be used to cover all parts not being assessed to provide as much privacy as possible.
The nurse is completing the abdominal portion of an admission assessment for a client admitted with asthmatic bronchitis who is otherwise healthy. What would the nurse expect to document? Select all that apply.
bowel sounds occurred every 5 to 34 seconds , soft, tinkling sounds in the right lower quadrant”
Rationale:Because the client is healthy otherwise, documentation should include abdominal findings that are within normal limit. Normoactive bowel sounds occur every 5 to 34 seconds and are soft, tinkling sounds. Hyperactive bowel sounds tend to be gurgling, continuous, and louder. Although a healthy person can have these sounds, they are not considered normal bowel sounds. Blowing, swooshing sounds at the ileac region would be documented as a bruit. Bowel sounds are considered absent after auscultating for 2 minutes in each quadrant with no sounds heard, and the client’s clinical picture should be considered.
The acute care nurse is assessing a newly admitted client’s abdomen. Which finding would indicate the need to contact the health care provider?
Auscultation of a bruit
Rationale:A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.
The nurse is conducting an initial assessment of the abdomen. When checking for vascular sounds in the abdomen, what should the nurse do? Select all that apply.
Expose only the region of the client being assessed. , Evaluate the aortic region of the abdomen first. , Assess the lower region of the abdomen last.
Rationale:When assessing the abdomen for vascular sounds, the nurse should use the bell, not the diaphragm of the stethoscope, expose only the region being assessed, and go from top to bottom in the artery areas. Listening for growling sounds would be assessing for Borborygmi, which is a bowel, not vascular sound.
The medical-surgical nurse is caring for a client admitted with gastroenteritis. Which assessment finding would indicate that the nurse should contact the health care provider?
Whooshing sound at the top of the abdomen near the aorta
Rationale:Whooshing sound at the top of the abdomen near the aorta may indicate an aneurysm or arterial stenosis and needs further assessment by the health care provider. Loud, gurgling in all four quadrants is normal with the expected increased motility of gastroenteritis and is called Borborygmi. The liver spans for about 6 to 12 cm and would be percussed as dull sounds at the right midclavicular line. Diffuse abdominal tenderness on palpation and cramping is common with gastroenteritis.
The emergency room nurse is caring for a client reporting severe right lower quadrant pain that had started as milder pain near the umbilicus. Vital signs include a fever of 38.6°C (101.5°F), pulse 92 bpm, respirations 24 breath/min, and blood pressure 136/80 mm Hg. What should the nurse do next? Select all that apply.
Begin an OR checklist , Keep the client NPO , Cleanse the abdomen with chlorhexidine
Rationale:The nurse would suspect acute appendicitis due to the pain location and vital signs. Thus, the client wound need to remain NPO and be immediately prepared for surgery, which includes applying the chlorhexidine cleanser to the abdomen and beginning an OR checklist. There is no need for a tap water enema or an antiemetic, because nausea or constipation are not mentioned in the assessment findings.
The nurse is preparing to assess a client’s abdomen. Place the following steps of the assessment in the correct order. Use all options.
1)Inspection2)Auscultation3)Percussion4)Palpation
