Question

A nurse is assessing four adult clients. Which of the followint physical assessment techniques should the nurse use?

A) Use the Face, Activity, Cry, and Consolability (FLACC) pain rating scale for the client who is experiencing pain.
B) Ensure the bladder of the blood pressure cull surounds 80% of the client's arm
C) Obtain an apical heart rate by ausculating at the thirsd intercostal space left of the sternum
D) Palpate the client's abdoment before auscuklating bowel sounds.

Answer 1

The nurse should use the FLACC pain rating scale for the client who is experiencing pain. The blood pressure cuff should surround 80% of the client's arm. The apical heart rate can be obtained by auscultating at the 5th intercostal space, midclavicular line and the abdomen should be palpated before auscultating bowel sounds.

Step-by-step explanation:

The nurse should use the Face, Activity, Cry, and Consolability (FLACC) pain rating scale for the client who is experiencing pain. This scale assesses pain in non-verbal patients, such as infants or those with cognitive impairments, by evaluating facial expression, activity level, cry, and ability to be consoled. The nurse can use this tool to accurately assess the intensity of the client's pain and implement appropriate interventions.

The nurse should also ensure that the bladder of the blood pressure cuff surrounds 80% of the client's arm. This ensures that the blood pressure reading is accurate and reliable. If the bladder of the cuff is too small or too large, it can lead to incorrect blood pressure measurements.

When obtaining an apical heart rate, the nurse should auscultate at the 5th intercostal space, midclavicular line. This is the correct location to listen to the heart sounds and accurately determine the client's heart rate.

It is important to palpate the client's abdomen before auscultating bowel sounds. Palpation helps to assess the abdomen for any tenderness, masses, or abnormalities before listening for bowel sounds.