Nokea
The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?
- A. Pain relief with knee flexion.
- B. Rebound tenderness in the right lower quadrant.
- C. Increased bowel sounds.
- D. Absence of fever.
Correct Answer: B
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis due to peritoneal irritation.
You may also like to solve these questions
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
A client is prescribed amiloride 10 mg orally daily for the treatment of hypertension. Which instruction should the nurse give the client regarding its administration?
- A. Take the medication in the morning with breakfast.
- B. Withhold the medication if the blood pressure is high.
- C. Eat foods with extra sodium while taking this medication.
- D. Take the medication 2 hours after lunch on an empty stomach.
Correct Answer: A
Rationale: Amiloride is a potassium-retaining diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid nocturia. Increased blood pressure is not a reason to hold the medication, and it may be an indication for its use. Sodium should be restricted if used as an antihypertensive. The dose should be taken with food to increase bioavailability.
A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response?
- A. I know how you feel, but the medication will make your child feel better.'
- B. I can't let you do this without calling your physician first.'
- C. Can you tell me why you want to take your child home now?'
- D. I can imagine how hard this is for you, but it's not what's best for the child.'
Correct Answer: C
Rationale: Asking the mother to explain her reasons encourages open communication and helps the nurse understand her concerns, facilitating appropriate support or intervention.
Select the arterial blood gas that you would report to the client's physician because it is not within normal parameters and it is also a significant change for the client.
- A. PaO2: 65 mm Hg
- B. PaCO2: 40 mm Hg
- C. Arterial blood pH: 7.39
- D. SaO2: 96%
Correct Answer: A
Rationale: PaO2 of 65 mm Hg is below the normal range (75-100 mm Hg), indicating hypoxemia, which requires reporting.
The nurse is assessing a client with a suspected spinal cord injury. Which of the following findings is most indicative of this condition?
- A. Loss of sensation below the injury site.
- B. Increased muscle tone in the arms.
- C. Normal bowel and bladder function.
- D. Absence of pain at the injury site.
Correct Answer: A
Rationale: Loss of sensation below the injury site is a hallmark sign of spinal cord injury due to disrupted nerve pathways.