Nurselogic Testing And Remediation Beginner (2024)

FAQs

When examining the abdomen, which of the following techniques should the nurse perform first? ›

Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.

Stage 2:Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.

Percussion produces sounds on a spectrum from flat to dull depending on the density of the underlying tissue. Areas of well-aerated lung will be resonant, or tympanic, to percussion. Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation.

Red flags that raise suspicion of serious pathology

Systemically unwell/septic-looking. Signs of dehydration. Rigid abdomen. Patient lying very still or writhing.

The five steps to palpating of the abdomen include: 1) Wash and warm your hands, 2) Communicate with the patient and palpate the most painful area last, 3) Palpate with light pressure then deep pressure, 4) Palpate all four quadrants, 5) Use a one- or two-handed technique.

In palpating the abdomen, one should first gently examine the abdominal wall with the fingertips. This will demonstrate the crunching feeling of crepitus of the abdominal wall, a sign of gas or fluid within the subcutaneous tissues.

Answer & Explanation. The priority assessment for a nurse caring for an immobile patient is to assess the patient's mobility status and need for assistance. Decisions made by nurses about ambulation, fall prevention, and handling and transferring procedures will be influenced by this assessment.

Document the frequency of repositioning required. Encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed.

Stage 4. The damage spreads to the muscle, bone, or joints. It can cause a serious bone infection called osteomyelitis. It can also lead to a possibly life-threatening blood infection called sepsis.

When percussing a client's chest, what should the nurse expect to hear? ›

Resonance is the normal sound heard when percussing the lungs because they are filled with air rather than dense tissue. However, it may be more of a dull or flat sound if a client has adipose tissue or a muscular chest, because this increased density modifies the sound.

Carefully review the patient's medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.

Normal percussion notes over abdominal region. With the exception of an area of dullness over the liver in the right lower anterior chest, tympany is the predominant sound heard over the region.

Begin your assessment by gently placing the diaphragm of your stethoscope on the skin in the right lower quadrant (RLQ), as bowel sounds are consistently heard in that area. Bowel sounds are generally high-pitched, gurgling sounds that are heard irregularly.

Following a quick assessment, the abdominal examination consists of 4 basic components—inspection, palpation, percussion, and auscultation. Inspection of the abdomen: The general examination of the abdomen begins with the patient in a completely supine position.

The correct sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation.