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NCLEX Practice TestBank-Interventions Nursing Practice Questions & Answers with Rationales 2020/2021

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NCLEX Practice TestBank-Interventions Nursing Question 1: (see full question) When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which ... of the following 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 auscultation may alter the sounds heard. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 Question 2: (see full question) The nurse in post-anesthesia recovery (PAR) is caring for a 27- year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain, the client 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. [Show More]

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