Question

1. A client has a diet order to start clear liquids. What assessment is the most important for the nurse to complete before initiating the diet order?

                a. Bowel sounds

                b. An orientation assessment

                c. Urine output

                d. Client preferences

2. What is the first assessment a nurse should complete when assessing the abdomen?

                a. Auscultation

                b. Palpation

                c. Inspection

d. percussion

3. Which assessment finding evaluating the urinary system requires the nurse to intervene?

                a. Urine output of 15mL/hour

                b. Urine yellow in color

C. Blood urea nitrogen (BUN): 15 mg/dL

d. Urine free of sediment

Answer 1

1.To start the oral feeds it is essential to assess the function of gastrointestinal system first.This can be assessed by asking for the passage of flatus by the patient or by auscultation of bowel sounds. These two indicates that peristalsis is present and return of gastric function post surgery or normal function of the gastrointestinal tract.

Urine output is measured to assess renal system,orientation,patient preference as a part of CNS assessment

Ans:a.Bowel sounds

2.The first assessment which the nurse had to do on abdomen is inspection of the abdomen for any redness ,distension ,vein distension ,color, any lesion ,umbilical for any discharge .

This has to be followed by auscultation for bowel sounds ,then percussion for fluid or air collection and finally palpation to assess any inflammation and tenderness

Ans:c.Inspection

3.A urine output of 30ml/hour or more is considered to be normal for a healthy person. If it is less than that it is the sign of some renal problem which has to be intervened immediately and provided care to prevent complications.

The urine is generally pale yellow or straw colored in nature.

The normal BUN ranges between 7 to 21mg/dl

A urine free of sediment is the normal reading

Ans:a.Urjne output of 15ml/hour