Nokea
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
- A. Inspect the abdomen for skin integrity.
- B. Ask the client about having a history of abdominal pain.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen in each of the four quadrants.
- E. Palpate the abdomen gently for tenderness.
Correct Answer: A,B,C,D,E
Rationale: Action to Take: A, B; Potential Condition: None; Parameter to Monitor: C, E.
Rationale:
1. Inspecting for skin integrity (A) allows the nurse to assess for any visible abnormalities or lesions.
2. Asking about abdominal pain history (B) provides insight into potential underlying conditions.
3. Auscultating for bowel sounds (C) helps assess gastrointestinal motility and function.
4. Percussing the abdomen (D) helps identify areas of abnormal fluid or gas accumulation.
5. Palpating for tenderness (E) assesses for pain or masses in the abdomen.
Summary:
- Not inspecting the abdomen (A) could miss skin abnormalities.
- Not asking about abdominal pain history (B) could overlook important medical information.
- Skipping auscultation (C) could lead to missing crucial gastrointestinal assessment.
- Not percussing (D) may result in overlooking potential abdominal issues.
- Omitting palpation (E) could miss detecting tend
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A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole 400 mg in 0.9% sodium chloride (NaCl) 200 mL to infuse over 2 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 100
Rationale: Correct Answer: 100
Rationale: To calculate the IV pump rate, use the formula: (Volume to be infused in mL) / (Time in hours). In this case, 200 mL over 2 hours. 200 / 2 = 100 mL/hr.
Summary:
A. Incorrect. Not the correct calculation for the IV pump rate.
B. Incorrect. Not the correct calculation for the IV pump rate.
C. Incorrect. Not the correct calculation for the IV pump rate.
D. Incorrect. Not the correct calculation for the IV pump rate.
E. Incorrect. Not the correct calculation for the IV pump rate.
F. Incorrect. Not the correct calculation for the IV pump rate.
G. Incorrect. Not the correct calculation for the IV pump rate.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
- A. Check the drainage for glucose.
- B. Notify the client’s provider.
- C. Document the amount of drainage.
- D. Obtain a culture of the drainage.
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (Choice A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
A nurse in a provider’s office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation?
- A. Low-grade fever
- B. Weight loss
- C. Anorexia
- D. Knuckle deformity
Correct Answer: D
Rationale: The correct answer is D: Knuckle deformity. Knuckle deformity in rheumatoid arthritis is a late manifestation due to prolonged inflammation and joint damage. This occurs after the initial symptoms such as low-grade fever, weight loss, and anorexia. Low-grade fever, weight loss, and anorexia are early systemic manifestations of RA caused by inflammation and metabolic changes. Knuckle deformity indicates advanced joint damage and chronic inflammation. Therefore, it is considered a late manifestation compared to the other options.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.