Nurs 3100 Exam 3 – Questions With Solutions
When performing an abdominal examination on a client, which assessment
technique should the nurse perform first?
A nurse assesses a client with a distended abdomen. Which action by the
nurse demonstrates the correct way to assess the client for ascites?
-auscultate for bowel sounds in all 4 quadrants
-palpate the abdomen lightly for areas of tenderness
-inspect the abdominal skin for vascularity
-percuss the flanks from the bed upward toward the umbilicus ✔️Ans -
percuss the flanks from the bed upward toward the umbilicus
Which action by the nurse will facilitate relaxation of the abdominal muscles
during examination of the abdomen?
-raise the client's arms or fold them behind the head
-avoid the use of a pillow behind the head during examination
-provide privacy to the client and instruct them to relax
-flex the client's legs by placing a pillow under the knees ✔️Ans - flex the
client's legs by placing a pillow under the knees
A nurse cares for a client with a distended abdomen due to peritonitis. Which
parameter should the nurse measure to assess improvement?
- auscultate for bowel sounds
- palpate the abdomen
- measure abdominal girth
- perform percussion for tympany ✔️Ans - measure abdominal girth
A nurse observes tenderness over the costovertebral angle on the right side.
The nurse recognizes this as an abnormal finding for which organ?
Which change in auscultation of bowel sounds should the nurse recognize as
diagnostic of an intestinal obstruction?
- an increase in the pitch
- no sound heard in 1 minute
- increase in the frequency of the gurgles
- a soft click every 5-15 seconds ✔️Ans - an increase in the pitch
During the abdominal exam, the nurse supports the client's right knee and
ankle, flexing the client's hip and rotating the leg internally and externally. At
this point, the client reports pain in the RLQ. This test is positive for which
sign?
A nurse inspects a client's abdomen and notices a large bulge is present in the
RLQ. How should the nurse further assess this finding using inspection?
- palpate to measure the diameter of the mass
- percuss to determine if the mass is fluid filled
- have the client cough forcefully a few times
- ask the client to raise the head off the bed ✔️Ans - ask the client to raise
the head off the bed
A client complains of a burning sensation of in the esophagus after eating.
Which associated condition should the nurse most suspect?
- acute pancreatitis
- pancreatic cancer
- acid reflux
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