Nokea
A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
- A. By checking the client's urine for blood
- B. By checking the client's stool for blood
- C. By checking the client's urine for a decrease in output
- D. By checking the client's bowel movements for diarrhea
Correct Answer: B
Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
You may also like to solve these questions
A nurse assisting with data collection plans to assess tactile (vocal) fremitus. The nurse performs this by using which technique?
- A. Palpating for symmetric chest expansion
- B. Auscultating the breath sounds over the trachea and larynx
- C. Auscultating the breath sounds over the peripheral lung fields
- D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word 'ninety-nine'
Correct Answer: D
Rationale: To assess tactile (vocal) fremitus, the nurse palpates the thorax and compares vibrations from side to side as the client repeats the word 'ninety-nine.' This technique helps in evaluating the intensity and symmetry of vibrations felt. Palpating for symmetric chest expansion involves assessing the expansion of the chest during breathing by placing hands on the anterolateral wall. Auscultating the breath sounds over the trachea and larynx is done to assess bronchial breath sounds, while auscultating over the peripheral lung fields is used to assess vesicular breath sounds.
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
- A. Insert a gloved finger into the mother's vagina to feel for cord compression
- B. Position the mother so that her hips are elevated
- C. Notify the registered nurse
- D. Perform a vaginal examination on the mother
Correct Answer: B
Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?
- A. Dull sounds
- B. Hyperresonance sounds
- C. Hypoactive bowel sounds
- D. An absence of bowel sounds
Correct Answer: A
Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.
A client is taught about healthy dietary measures and the MyPlate food plan. How many of his grains should be whole grains according to the MyPlate food plan?
- A. One-quarter
- B. One-third
- C. One-half
- D. Two-thirds
Correct Answer: C
Rationale: The correct answer is 'One-half.' According to the MyPlate food plan, at least half of the grains consumed daily should be whole grains. This ensures a well-balanced and healthy diet. Choices A, B, and D are incorrect because they do not align with the dietary recommendation provided by the MyPlate food plan. One-quarter, one-third, and two-thirds do not represent the appropriate proportion of whole grains as advised by the plan, which emphasizes the importance of including a significant portion of whole grains in one's diet.
When preparing to listen to a client's breath sounds, what technique should a nurse use?
- A. Ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap.
- B. Listen to the right lung first, then the left lung, moving from top to bottom systematically.
- C. Ask the client to take deep breaths through the mouth.
- D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest.
Correct Answer: D
Rationale: When preparing to listen to a client's breath sounds, a nurse should ask the client to sit and lean forward slightly, with the arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little more deeply than usual but to stop if feeling dizzy. The nurse should use the flat diaphragm end-piece of the stethoscope, holding it firmly on the chest wall. By using the diaphragm, the nurse can listen for at least one full respiration in each location, moving from side to side to compare sounds. This technique ensures a systematic and thorough assessment of lung sounds. Choice A is correct as it includes the proper positioning of the client and specifies the use of the diaphragm of the stethoscope. Choice B is incorrect as both lungs should be auscultated systematically, starting from the top and moving down. Choice C is incorrect as deep breaths, not shallow ones, are recommended for an accurate assessment of breath sounds.