The nurse is preparing to examine a patient who has been ...

[tingc95]

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:
 
  a. Examine the tender area first.
  b. Examine the tender area last.
  c. Avoid palpating the tender area. d.
  Palpate the tender area first, and then auscultate for bowel sounds.

Question 2

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:
 
  a. Splenomegaly.
  b. Distended bladder.
  c. Constipation.
  d. Ascites.

[aloop]

Answer to Question 1

ANS: B
The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Answer to Question 2

ANS: D
If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

[tingc95]

TYSM

[AmberC1996]

Excellent