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1. Question
A client is experiencing acute abdominal pain. Which abdominal assessment sequence is appropriate for the nurse to use for examination of the abdomen?
Correct
Answer B is correct.
Rationale: Inspect, auscultate, palpate, and percuss is the correct sequence of assessing the abdomen. The initial step is to inspect the abdomen. Auscultation must be accomplished before touching because movement could make auscultation inaccurate. Answers A, C, and D are incorrect assessment sequences.
Incorrect
Answer B is correct.
Rationale: Inspect, auscultate, palpate, and percuss is the correct sequence of assessing the abdomen. The initial step is to inspect the abdomen. Auscultation must be accomplished before touching because movement could make auscultation inaccurate. Answers A, C, and D are incorrect assessment sequences.
Assessing the abdomen:
When assessing the abdomen, first observe for changes in abdominal contour. Abdominal dressings, tubes, or other devices may distort this contour. To detect asymmetry, view the abdomen from the foot of the patient’s bed. Also, observe for Cullen’s sign, a bluish hue around the umbilicus that commonly accompanies intra-abdominal or peritoneal bleeding.
Auscultation station
Auscultate bowel sounds for at least 1 minute in each of the four quadrants. You probably won’t be able to detect bowel sounds for 6 hours or more after surgery because general anesthetics slow peristalsis. If the surgeon handled the patient’s intestines during surgery, bowel sounds will be absent even longer.