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During a physical assessment the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Diarrhea
Correct Answer: D
Rationale: Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.
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The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be?
- A. 1 second
- B. 2 seconds
- C. 3 seconds
- D. 4 seconds
Correct Answer: C
Rationale: Capillary refill should take fewer than 3 seconds.
A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.
A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Lateral recumbent
Correct Answer: D
Rationale: The lateral recumbent position aids in detecting heart murmurs.
During a physical assessment the nurse notes a patient has a loss of strength and energy. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Asthenia
- D. Ecchymosis
Correct Answer: C
Rationale: Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.
A nurse needs to auscultate a patient's lung sounds. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Sitting
- D. Lithotomy
Correct Answer: C
Rationale: Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts.