Question

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

a. Inspect

b. Auscultate

c. Percuss

d. Palpate

Answer 1

The correct sequence for an abdominal assessment is to Inspect, Auscultate, Percuss, and then Palpate, following a methodology that ensures auscultation is not influenced by the manipulation of percussion and palpation.

Step-by-step explanation:

Abdominal Assessment Sequence

When a nurse is conducting an abdominal assessment on a patient, the correct sequence of actions to follow is:

1. Inspect: Examine the abdomen visually to note any abnormalities such as distension, scars, or skin changes.
2. Auscultate: Use a stethoscope to listen to bowel sounds and vascular sounds to assess for normal or abnormal findings.
3. Percuss: Tap on the abdomen to discern the quality of sounds produced, which can indicate the presence of fluids, air, or solid masses.
4. Palpate: Gently press on the abdomen to feel for any abnormalities or tenderness which may indicate underlying issues.

By following this specific sequence, auscultation is not influenced by the subsequent manipulation of the abdomen that occurs during percussion and palpation, allowing for more accurate assessment of bowel sounds.