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The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
- A. Palpate over the area to identify increased pain and tenderness.
- B. Ask the child to take shallow breaths, and percuss over the area again.
- C. Refer the child immediately because of suspicion of an increased amount of air in the lungs.
- D. Consider this a normal finding for a child this age, and proceed with the examination.
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.
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A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
- A. Fatigue and shortness of breath.
- B. Increased urine output.
- C. Decreased blood pressure.
- D. Pitting edema and weight gain.
Correct Answer: D
Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
- A. Severe headache
- B. Dehydration
- C. Respiratory depression
- D. Sudden loss of vision
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for signs of which of the following complications?
- A. Pulmonary embolism.
- B. Gastrointestinal bleeding.
- C. Deep vein thrombosis (DVT).
- D. Hypoglycemia.
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.
What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?
- A. Constipation
- B. Air-filled areas
- C. The presence of a tumor
- D. The presence of dense organs
Correct Answer: B
Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination.
Incorrect Answers:
A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention.
C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion.
D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.
A nurse is providing discharge instructions to a patient with chronic hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication even when my blood pressure is normal.
- C. I can stop taking my medication if I feel fine.
- D. I will avoid high-sodium foods.
Correct Answer: C
Rationale: The correct answer is C because stopping medication without consulting a healthcare provider can lead to uncontrolled hypertension. Choice A shows understanding of monitoring blood pressure, B demonstrates adherence to medication regimen, and D indicates awareness of dietary management. Choice C is incorrect because abruptly stopping medication can have serious health consequences, making further education necessary.