Which sequence should the nurse follow when collecting data for an abdominal examination?
inspection of the outer appearance, auscultation of bowel and arterial sounds, percussion, and palpation of the tissue and underlying structures
inspection of the outer appearance, percussion and palpation of the tissue and underlying structures, and auscultation of bowel and arterial sounds
inspection of the outer appearance, auscultation of bowel and arterial sounds, and palpation and percussion of the tissue and underlying structures
inspection, palpation, percussion, and auscultation
The nurse is caring for a client who is concerned about skin cancer. Abnormal characteristics of pigmented skin lesions are defined by the mnemonic ABCDE. What does the mnemonic mean?
asymmetry, black/brown, consistency, diameter, erythema
asymmetry, border, color, diameter, elevation/enlargement
asymmetry, black/brown, consistency, diameter, erythema
ashen, border, color, diameter, elevation/enlargement
A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?
Complete the client's registration information, perform an electrocardiogram (ECG), gain I.V. access, and take vital signs.
Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.
Gain IV access, give sublingual nitroglycerin and a dose of aspirin, and alert the cardiac catheterization team.
Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the primary care provider.
A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?
weak, irregular pulse; cool, moist skin; and hypotension
restlessness, confusion, increased urine output, and warm, dry skin
cyanosis, nausea, vomiting, and constricted pupils
even, unlabored respirations; tachycardia; and hemoptysis
A client with type 1 diabetes has a leg infection that is being treated with antibiotics, wet-to-dry dressings, and whirlpool therapy. Since the infection began, the client's blood glucose levels have been unstable. Which data collected by the nurse indicate a serious complication?
Flushed cheeks, dry mouth, and acetone breath odor
Mental changes, fever, and hand tremors
Headache, sweating, and nervousness
Periods of rapid breathing followed by absence of breathing, picking at the bed linens, and nausea
A nurse is preparing to perform an abdominal assessment. Which sequence would the nurse follow to effectively perform an abdominal examination on a client?
Inspection, auscultation, palpation, and percussion
Inspection, palpation, percussion, and auscultation
Inspection, percussion, palpation, and auscultation
Inspection, auscultation, percussion, and palpation