Nokea
During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?
- A. Concave, midline umbilicus
- B. Pulsation between the umbilicus and pubis
- C. Bowel sound frequency of 15 sounds per minute
- D. Absence of a bruit
Correct Answer: B
Rationale: The correct answer is B because pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm (AAA), a serious condition that requires immediate medical attention. The pulsation in this area could be the enlargement of the aorta, which can be life-threatening if it ruptures. Reporting this finding to the physician is crucial for further evaluation and intervention.
Choice A (Concave, midline umbilicus) is incorrect because it is a normal finding during an abdominal assessment. Choice C (Bowel sound frequency of 15 sounds per minute) is incorrect as it falls within the normal range of bowel sounds. Choice D (Absence of a bruit) is also incorrect as the absence of a bruit is a normal finding and does not indicate any immediate concern.
You may also like to solve these questions
A nurse orientee is preparing to insert a nasogastric tube, and a nurse educator is observing the procedure. Which of the following supplies if obtained by the nurse orientee would indicate a need for further education regarding this procedure?
- A. Half-inch or one-inch tape
- B. Oil-soluble lubricant
- C. A glass of tap water with a straw
- D. A 50-mL catheter tip syringe
Correct Answer: B
Rationale: The correct answer is B: Oil-soluble lubricant. The rationale is that oil-based lubricants should not be used for nasogastric tube insertion due to the risk of aspiration pneumonia. The other options are appropriate for the procedure: A) Tape is used to secure the tube, C) Water with a straw is used to check tube placement, and D) A syringe is used for verification of tube placement and administration of medications. Therefore, selecting B indicates a lack of understanding of proper supplies for nasogastric tube insertion.
A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I'm not sure I can avoid alcohol.' The most appropriate response is
- A. Everything will be alright.
- B. I think you should talk more with the doctor about this.
- C. I don't believe that.
- D. I'm not sure that I don't understand. Would you please explain?
Correct Answer: D
Rationale: The correct answer is D because it shows active listening and empathy towards the client's concerns. By asking the client to explain, the nurse can gain a better understanding of the client's perspective and provide tailored support and information. Choice A is incorrect as it dismisses the client's concerns. Choice B is incorrect as it deflects responsibility from the nurse. Choice C is incorrect as it shows disbelief and lacks empathy.
A nurse is providing the client with biliary obstruction a simple overview of the anatomy of the liver and gallbladder. The nurse tells the client that normally the liver stores bile in the gallbladder, which is connected to the liver by the?
- A. Liver canaliculi
- B. Common bile duct
- C. Cystic duct
- D. Right hepatic duct.
Correct Answer: C
Rationale: The correct answer is C: Cystic duct. The cystic duct connects the gallbladder to the common bile duct, through which bile flows from the liver to the gallbladder for storage. The liver canaliculi are tiny channels within the liver where bile is produced. The common bile duct is the main duct through which bile flows from the liver to the small intestine. The right hepatic duct is one of the ducts that collect bile from the liver but does not directly connect to the gallbladder. Therefore, the cystic duct is the correct choice as it specifically links the gallbladder to the common bile duct for bile transportation.
The nurse assesses the client's understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?
- A. I can elevate the foot of the bed 4 to 6 inches.
- B. I can sleep on my stomach with my head turned to the left.
- C. I can sleep on my back without a pillow under my head.
- D. I can elevate the head of the bed 4 to 6 inches.
Correct Answer: D
Rationale: The correct answer is D: "I can elevate the head of the bed 4 to 6 inches." Elevating the head of the bed helps to prevent gastroesophageal reflux by promoting gravity to keep stomach acid from moving back into the esophagus. This position helps to keep the stomach contents in place and reduces the likelihood of reflux during sleep.
Choice A is incorrect because elevating the foot of the bed would not be effective in preventing reflux; it may even exacerbate the issue. Choice B is incorrect as sleeping on the stomach can increase pressure on the stomach and worsen reflux. Choice C is also incorrect as sleeping on the back without a pillow under the head may not provide the necessary elevation to prevent reflux effectively.
The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation?
- A. Distilled water
- B. Tap water
- C. Sterile water
- D. Lactated Ringer's
Correct Answer: B
Rationale: The correct answer is B: Tap water. Tap water is used for colostomy irrigation as it is isotonic and won't disrupt electrolyte balance. Distilled water (A) can cause electrolyte imbalances. Sterile water (C) may not be necessary, and Lactated Ringer's (D) is not typically used for colostomy irrigation.