Nokea
The nurse is assessing a client with complaints of right lower quadrant pain.
- A. Which assessment technique should the nurse use first to assess a client with right lower quadrant pain?
- B. Inspect the abdomen for distention or masses.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen for tympany or dullness.
- E. Palpate the abdomen for tenderness or rebound.
Correct Answer: A
Rationale: Inspection is the first step in abdominal assessment, allowing the nurse to observe for distention, masses, or visible abnormalities before proceeding to auscultation, percussion, and palpation. Palpation last prevents discomfort that could alter other findings.
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A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
A client with acromegaly will most likely experience which symptom?
- A. Bone pain
- B. Frequent infections
- C. Fatigue
- D. Weight loss
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
The nurse is caring for a client who is 2 days postoperative after a cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 99.5°F (37.5°C).
- B. Pain at the incision site.
- C. Yellowish drainage from the incision.
- D. Urine output of 1500 mL in 24 hours.
Correct Answer: C
Rationale: Yellowish drainage from the incision suggests infection or bile leakage, a serious complication post-cholecystectomy requiring immediate evaluation. Options A, B, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.