A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. Move the steps into the box in order of performance:
Inspection
Auscultation
Superficial palpation
Deep palpation
Correct Answer : A,B,C,D
The correct answer is a) Inspection, b) Auscultation, c) Superficial palpation, d) Deep palpation.
Choice A reason:
Inspection is the first step in an abdominal assessment. This involves visually examining the abdomen for any abnormalities such as distension, scars, lesions, or asymmetry. The nurse should note the shape, contour, and any visible movements or pulsations. This step is crucial as it provides the initial information about the patient’s condition and helps guide the subsequent steps of the assessment.
Choice B reason:
Auscultation follows inspection in the sequence of an abdominal assessment. The nurse uses a stethoscope to listen for bowel sounds in all four quadrants of the abdomen. This step is performed before palpation to avoid altering the natural bowel sounds. The presence, frequency, and character of bowel sounds can provide valuable information about the gastrointestinal function and help identify any abnormalities such as bowel obstruction or ileus.
Choice C reason:
Superficial palpation is the third step in the abdominal assessment sequence. The nurse gently palpates the abdomen to assess for tenderness, muscle tone, and any superficial masses. This step helps identify areas of discomfort or pain and provides information about the condition of the abdominal wall and underlying structures. It is important to perform this step gently to avoid causing discomfort or pain to the patient.
Choice D reason:
Deep palpation is the final step in the abdominal assessment sequence. The nurse applies more pressure to palpate deeper structures within the abdomen. This step helps assess for any deep-seated masses, organ enlargement, or areas of tenderness that were not detected during superficial palpation. Deep palpation should be performed carefully to avoid causing pain or discomfort to the patient.
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Correct Answer is ["B","C","D"]
Explanation
Choice A: Increase Sodium Intake
Increasing sodium intake is generally not recommended for patients with renal disorders. High sodium intake can lead to fluid retention, hypertension, and worsening of kidney function. Patients with renal disorders are often advised to follow a low-sodium diet to manage these risks.
Choice B: Monitor Intake/Output
Monitoring intake and output (I/O) is crucial for patients with renal disorders. It helps in assessing kidney function and fluid balance. Accurate measurement of fluid intake and urine output can provide valuable information about the patient’s hydration status and kidney function. This intervention is essential for preventing fluid overload and dehydration.
Choice C: Daily Weights
Daily weights are an important intervention for patients with renal disorders. Monitoring weight daily helps in detecting fluid retention early. Sudden weight gain can indicate fluid overload, which is a common issue in patients with kidney problems. By tracking daily weights, healthcare providers can make timely adjustments to the patient’s treatment plan.
Choice D: Monitor Blood Pressure
Monitoring blood pressure is a key intervention for patients with renal disorders. Hypertension is both a cause and a consequence of kidney disease. Regular monitoring of blood pressure helps in managing hypertension and preventing further damage to the kidneys. It also aids in assessing the effectiveness of antihypertensive medications.
Correct Answer is B
Explanation
Choice A reason:
Assessing fluid intake is important in managing dehydration, but it is not the most critical assessment before initiating an IV infusion containing potassium chloride (KCL). Fluid intake provides information about the child’s hydration status but does not directly indicate kidney function. Since potassium can cause hyperkalemia if not properly excreted, monitoring urine output is more crucial.
Choice B reason:
Urine output is the most important assessment before initiating an IV infusion containing potassium chloride (KCL). This is because adequate urine output indicates that the kidneys are functioning properly and can excrete excess potassium. Administering potassium chloride without ensuring proper kidney function can lead to hyperkalemia, a potentially life-threatening condition. Therefore, checking urine output is essential to prevent complications.
Choice C reason:
Capillary refill is a useful assessment for evaluating peripheral perfusion and hydration status. However, it does not provide direct information about kidney function or the body’s ability to excrete potassium. While capillary refill can be part of the overall assessment, it is not the most critical factor before administering an IV infusion with potassium chloride.
Choice D reason:
The number of stools is relevant in assessing dehydration, especially if the child has been experiencing diarrhea. However, like fluid intake, it does not directly indicate kidney function. Monitoring urine output is more important before administering potassium chloride to ensure the kidneys can handle the additional potassium load.