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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A Reason:
“Watch how well I blow these bubbles” is not a concerning statement. It indicates that the child is engaging in normal activities and is not experiencing any distress related to the cast or the injury.
Choice B Reason:
“My skin is so itchy under there” is a common complaint among children with casts. Itchiness can be managed with appropriate care, such as using a hair dryer on a cool setting to blow air under the cast. However, it is not an immediate cause for concern.
Choice C Reason:
“My toes feel like they are sleeping and won’t wiggle when I tell them to” is a concerning statement. This could indicate nerve compression or impaired circulation, which are serious complications that require immediate medical attention. Prompt evaluation is necessary to prevent permanent damage.
Choice D Reason:
“I was able to ride on the scooter with the PT person’s help” is not a concerning statement. It suggests that the child is participating in physical therapy and is able to move with assistance, which is a positive sign of recovery.
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.