A practical nurse (PN) is assigned to collect data on a client who is admitted with severe abdominal cramping and frequent vomiting. In which order should the PN perform the abdominal data collection techniques? Arrange the actions in the correct sequence.
- 1Position the client supine with the knees slightly flexed and ensure privacy.
- 2Visually inspect the abdomen for contour, symmetry, and visible peristalsis.
- 3Auscultate all four quadrants for bowel sounds, starting in the right lower quadrant.
- 4Lightly palpate the abdominal quadrants to identify areas of tenderness or muscle guarding.
- 5Document the collected data and immediately report any rigid areas to the registered nurse.
Cevap
The correct sequence is to position the client, inspect the abdomen, auscultate bowel sounds, lightly palpate for tenderness, and then document and report the findings.
The correct sequence for an abdominal assessment deviates from standard physical assessment protocols. To prevent altering the client's baseline bowel sounds, the nurse must inspect first, then auscultate, followed by palpation. Proper positioning sets up the assessment, and documentation concludes the process.
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Abdominal Data Collection Sequence