Question

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

A. use the face, legs, activity, cry, and consolability pain rating scale for a clinet who is experiencing pain
B. ensure the bladder of the bp culf surrounds 80% of client's arm
C. obtain a apical heart rate by ausculating at the third (should be 5th) intercostal space left on the sternum
D. palpate the client's abdomen before ausculating bowel sounds

Answer 1

A nurse should use a pain rating scale for adults, ensure the correct placement of the blood pressure cuff for accurate readings, auscultate for the apical heart rate at the appropriate location, and auscultate before palpating the abdomen.

Step-by-step explanation:

The nurse should use various assessment techniques tailored to the situation of each adult client. When assessing pain, it is important to use a pain rating scale that is appropriate for adults, such as the numerical rating scale or the Wong-Baker FACES scale. For a blood pressure reading, the correct practice is to ensure the bp cuff surrounds about 80% of the client's upper arm, not necessarily a specific percentage. As for the apical heart rate, it should be auscultated at the fifth intercostal space to the left of the sternum, not the third. Lastly, when examining the abdomen, the proper procedure is to auscultate bowel sounds before palpation to ensure the sounds are not altered by the palpation.