NCLEX Nursing Interventions TEST BANK 2022/2023 , Download to score an A

Question 1: When performing an abdominal assessment, the nurse

uses a

(see full question) different order of techniques than with other systems.

Which of thefollowing represents this order

You selected: Inspection, auscultation, percussion, palpation

Correct

Explanation: In an abdominal assessment, start with inspection, 

then auscultation, percussion, and palpation. This is 

the preferred approach because palpation and

percussion before auscultationmay alter the sounds 

heard. (less)

Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. 

Philadelphia: Wolters Kluwer Health/Lippincott

Williams & Wilkins; 2015, Chapter25: Health

Assessment, p. 658.

Chapter 25: Health Assessment - Page 658

Question 2: The nurse in post-anesthesia recovery (PAR) is caring for

a 27-

(see full question) year-old client following an appendectomy. Twenty 

minutes after receiving 4 mg of intravenous (IV)

morphine for abdominal pain, theclient continues to 

report abdominal discomfort and requests more

morphine. Which action by the nurse is best?

You selected: Observe the abdomen for distention and rigidity.

Correct

Explanation: Continued abdominal pain after administration of IV 

morphine is an unexpected occurrence and requires 

further assessment by the nurse to rule out peritonitis 

or internal bleeding by observing the abdomen for 

distention and rigidity. Administration of more

morphine could mask the cause of the abdominal pain 

and delay diagnosis of a possible postoperative 

complication. Applying heat tothe abdomen would 

increase blood flow to the area and potentially increase 

pain or internal bleeding. Positioning the client in a 

knees-flexed position may relieve the discomfort, but an 

assessment is needed before any intervention is

implemented.