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Select the sequence of techniques used during an examination of the abdomen.

A.

Percussion, inspection, palpation, auscultation.

B.

Inspection, palpation, percussion, auscultation.

C.

Inspection, auscultation, percussion, palpation.

D.

Auscultation, inspection, palpation, percussion.

Answer and Explanation

The Correct Answer is C

A. Percussion, inspection, palpation, auscultation: This sequence could disturb bowel sounds by percussing before auscultation, making it difficult to assess them accurately.

 

B. Inspection, palpation, percussion, auscultation: Palpating before auscultating can alter bowel sounds, so it’s not the correct order.

 

C. Inspection, auscultation, percussion, palpation: This sequence is recommended for abdominal assessment to avoid altering bowel sounds. Inspection is done first to observe any visible abnormalities, followed by auscultation to listen to bowel sounds before palpating or percussing, which could disrupt the sounds.

 

D. Auscultation, inspection, palpation, percussion: Inspection should always be first, making this option incorrect as it begins with auscultation.


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Correct Answer is ["A","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

Correct Answer is C

Explanation

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

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