Question

The nurse is performing a focuses assessment of the abdomen and uses the following techniques. Which technique is correct?

Answer 1

Correct Answers:

Inspect the abdomen for asymmetry and masses first.

Rationale :

💎 The correct order of abdominal assessment is inspection → auscultation → percussion → palpation to prevent altering bowel sounds or causing discomfort.

💎 The nurse should first inspect for asymmetry, distention, scars, or visible masses before touching the abdomen.

💎 Early visualization helps identify abnormalities such as hernias or visible peristalsis.

💎 Performing auscultation before palpation prevents stimulating bowel sounds that could lead to inaccurate findings.

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Answer 2

Correct Answers:

Place the client supine with knees bent.

Rationale :

🔷 Evisceration is a medical emergency where abdominal contents protrude through a surgical incision.

🔷 The nurse should immediately place the client in a supine position with knees bent to reduce abdominal muscle tension and pressure on the wound.

🔷 This position helps prevent further protrusion or tearing of tissues.

🔷 After positioning, the nurse should cover the wound with a sterile saline-moistened dressing and monitor for signs of shock while awaiting surgical intervention.

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Answer 3

Correct Answers:

Hypertension
Sedentary lifestyle
Alcohol consumption

Rationale :

💎 1️⃣ Hypertension

✔️Hypertension (high blood pressure) is a major modifiable risk factor for cardiovascular disease, stroke, and kidney failure.

✔️It can be reduced through lifestyle modifications such as a low-sodium diet, regular exercise, stress management, and maintaining a healthy weight.

✔️Clients should be encouraged to monitor their blood pressure regularly and adhere to prescribed antihypertensive medications if needed.

✔️Teaching should emphasize the DASH diet (Dietary Approaches to Stop Hypertension), which includes fresh fruits, vegetables, lean proteins, and limited processed foods.

✔️Managing blood pressure lowers the risk of heart attack, stroke, and other vascular complications.

🔷 2️⃣ Sedentary Lifestyle

✔️A sedentary lifestyle increases the risk of obesity, type 2 diabetes, hypertension, and heart disease.

✔️Lack of physical activity reduces circulation, muscle tone, and metabolism, leading to fat accumulation and poor cardiovascular conditioning.

✔️The nurse should encourage at least 150 minutes of moderate exercise per week, such as brisk walking, swimming, or cycling.

✔️Regular physical activity improves cardiovascular endurance, helps control blood glucose and cholesterol, and enhances mental well-being.

✔️Making movement part of daily life—like using stairs, walking breaks, or home workouts—can drastically reduce chronic disease risk.

🟢 3️⃣ Alcohol Consumption

✔️Excessive alcohol intake is linked to liver disease, hypertension, stroke, and certain cancers, making it a modifiable lifestyle risk factor.

✔️Alcohol also increases triglyceride levels and may interfere with medications, particularly antihypertensives and anticoagulants.

✔️The nurse should educate on safe drinking limits—no more than one drink per day for women and two for men, as per CDC guidelines.

✔️Encouraging clients to limit or abstain from alcohol promotes liver health, stabilizes blood pressure, and supports weight control.

✔️Reducing alcohol intake also improves sleep quality, cognitive function, and emotional stability.

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Answer 4

Correct Answers:

Receive medical screening and treatment

Rationale :

🔶 Under the Emergency Medical Treatment and Labor Act (EMTALA), every individual has the right to receive an emergency medical screening and stabilization regardless of insurance, ability to pay, or nationality.

🔶 Hospitals cannot delay care to request insurance or payment information.

🔶 Transfer to another hospital can occur only after stabilization or when specialized care is required.

🔶 This ensures equal access to emergency care and prevents patient dumping.

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Answer 5

Correct Answers:

Ask the client to state the surgery being performed
Verify that the surgical site has been marked
Ask the client to read their identification bracelet
Use two acceptable chant identifiers

Rationale :

💎 1️⃣ Ask the client to state the surgery being performed

🟢During the time-out procedure, the nurse must actively involve the client by asking them to verbalize the procedure they are expecting to undergo.

🟢This step ensures that the client’s understanding matches the surgical consent and prevents wrong-procedure or wrong-site surgery.

🟢Active confirmation by the patient adds an extra layer of safety verification beyond chart reviews.

🟢If the client’s response differs from the scheduled procedure, the nurse must pause the process and clarify with the surgical team before proceeding.

🟢Including the patient in verification reinforces patient-centered care and accountability.

🔷 2️⃣ Verify that the surgical site has been marked

🟢Surgical site marking is a critical safety step for procedures involving right/left or multiple-site operations (e.g., limbs, kidneys, eyes).

🟢The nurse should verify that the surgeon marked the site with an indelible marker before sedation and that it matches the operative consent form.

🟢This confirmation prevents wrong-site surgery, a sentinel event with serious consequences.

🟢The mark should be visible after skin prep and draping. If unclear or missing, the nurse must stop the procedure until verified.

🟢Proper marking aligns with Joint Commission’s Universal Protocol to ensure surgical accuracy and safety.

🟢 3️⃣ Ask the client to read their identification bracelet

🟢Having the client read their own ID bracelet aloud helps confirm correct identification and ensures the right patient is about to undergo surgery.

🟢The nurse compares this information to the surgical consent form, health record, and schedule.

🟢This step also helps detect clerical errors or mix-ups, especially in facilities with multiple patients having similar names.

🟢If the client is unable to speak (e.g., sedated or nonverbal), verification must be done using two identifiers and confirmed by the care team.

🟢Proper identification is a legal and ethical priority before any invasive procedure.

🔶 4️⃣ Use two acceptable client identifiers

🟢The nurse must always confirm patient identity using two unique identifiers, such as name and date of birth, or medical record number—never a room or bed number.

🟢This ensures the correct patient receives the correct treatment and eliminates potential human error.

🟢The identifiers are compared to the surgical consent form, medical record, and provider order during the time-out.

🟢This process follows national patient safety goals established by the Joint Commission to reduce preventable errors.

🟢Proper identification is especially vital before procedures involving anesthesia, transfusions, or invasive interventions.

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Answer 6

Correct Answers:

Prolonged grief

Rationale :

🟣 Prolonged (complicated) grief occurs when a person is unable to move forward after a significant loss and continues to experience intense yearning or emotional pain beyond 12 months.

🟣 Symptoms include preoccupation with the deceased, difficulty engaging in daily life, and denial of the loss.

🟣 The nurse should assess for depression or suicidal ideation and may refer the client for grief counseling or therapy.

🟣 Unlike uncomplicated grief, prolonged grief interferes with functioning and may require professional support.

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Answer 7

Correct Answers:

refers to the intervention to be compared during the researched

Rationale :

💠 The PICOT framework in evidence-based practice stands for:

P: Population or patient problem

I: Intervention

C: Comparison

O: Outcome

T: Time frame

💠 The “C” in PICOT refers to the intervention or standard practice being compared to the new approach being tested.

💠 Using PICOT helps structure clinical questions that lead to focused, research-based decision-making.

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Answer 8

Correct Answers:

Wash the client's body

Rationale :

🟢 During postmortem care, the nurse should gently wash and prepare the client’s body to maintain dignity and cleanliness before viewing or transfer to the morgue.

🟢 Dentures are left in place to maintain facial structure, and the head of the bed is elevated to prevent discoloration and pooling of blood.

🟢 Personal items are handled respectfully and according to facility policy and family wishes.

🟢 The room should be quiet, clean, and well-lit, allowing family members time for final goodbyes.

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Answer 9

Correct Answers:

It's very normal for a child this age to have imaginary playmates."

Rationale :

💎 Between ages 3 to 7 years, imaginary friends are a normal part of creative and cognitive development.

💎 Pretend play allows children to practice social roles, express emotions, and develop problem-solving skills.

💎 The nurse should reassure the mother that this behavior is typical and healthy unless it causes distress or impairs functioning.

💎 The nurse may suggest encouraging imaginative play as it fosters emotional growth.

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Answer 10

Correct Answers:

Gloves

Rationale :

🔷 After performing a wound irrigation under contact precautions, the nurse should remove gloves first because they are the most contaminated.

🔷 Removing gloves before other PPE prevents cross-contamination during doffing.

🔷 The correct PPE removal sequence is: Gloves → Gown → Face shield → Mask.

🔷 Hand hygiene should be performed immediately afterward to prevent infection transmission.

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QLexNursing

1 :
The nurse is performing a focuses assessment of the abdomen and uses the following techniques. Which technique is correct?

2 :
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help. Which of the following actions should the nurse take first?

3 :
A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select All that Apply.)

4 :
A nurse in the emergency department is caring for a client experiencing a new episode of COPD exacerbation. The nurse should identify which of the following is a client right related to the Emergency Medical Treatment and Labor Act (EMTALA)?

5 :
A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? (Select All that Apply)

6 :
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should sowerofy that the cent has manifestations of which of the following types of grief?

7 :
A nurse is discussing the process of evidence-based practice with a newly licensed nurse. Which of the following information should the nurse include when discussing a PICOT question?

8 :
A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

9 :
A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern?

10 :
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

QLexNursing

1 : The nurse is performing a focuses assessment of the abdomen and uses the following techniques. Which technique is correct?

2 : A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help. Which of the following actions should the nurse take first?

3 : A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select All that Apply.)

4 : A nurse in the emergency department is caring for a client experiencing a new episode of COPD exacerbation. The nurse should identify which of the following is a client right related to the Emergency Medical Treatment and Labor Act (EMTALA)?

5 : A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? (Select All that Apply)

6 : A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should sowerofy that the cent has manifestations of which of the following types of grief?

7 : A nurse is discussing the process of evidence-based practice with a newly licensed nurse. Which of the following information should the nurse include when discussing a PICOT question?

8 : A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

9 : A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern?

10 : A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?

1 :
The nurse is performing a focuses assessment of the abdomen and uses the following techniques. Which technique is correct?

2 :
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help. Which of the following actions should the nurse take first?

3 :
A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select All that Apply.)

4 :
A nurse in the emergency department is caring for a client experiencing a new episode of COPD exacerbation. The nurse should identify which of the following is a client right related to the Emergency Medical Treatment and Labor Act (EMTALA)?

5 :
A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? (Select All that Apply)

6 :
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should sowerofy that the cent has manifestations of which of the following types of grief?

7 :
A nurse is discussing the process of evidence-based practice with a newly licensed nurse. Which of the following information should the nurse include when discussing a PICOT question?

8 :
A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

9 :
A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern?

10 :
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following personal protective equipment (PPE) should the nurse remove first?