Nokea
The nurse is assessing an alert and independent older-adult patient in the clinic for malnutrition risk. Which of the following questions is best as the initial assessment question?
- A. How do you get to the grocery store to buy your food?
- B. Do you have any difficulty in preparing or eating food?
- C. Can you tell me the foods that you have eaten over the past 24 hours?
- D. Are you taking any medications that alter your taste or tolerance of foods?
Correct Answer: C
Rationale: This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.
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During change-of-shift report, the nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure?
- A. The patient has a permanent pacemaker to prevent bradycardia.
- B. The patient is worried about discomfort during the examination.
- C. The patient has had an allergic reaction to shellfish and iodine in the past.
- D. The patient refused to drink the ordered polyethylene glycol.
Correct Answer: D
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.
Which of the following assessment findings in a patient who is being admitted to the hospital is most important to report to the health care provider?
- A. Tympany on percussion of the abdomen
- B. Liver edge 3 cm below the costal margin
- C. Bowel sounds of 20/minute in each quadrant
- D. Aortic pulsations visible in the epigastric area
Correct Answer: B
Rationale: Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.
The nurse is caring for a patient who has an obstruction of the common bile duct. Which of the following findings should the nurse monitor in this patient?
- A. Melena
- B. Steatorrhea
- C. Decreased serum cholesterol levels
- D. Increased serum indirect bilirubin levels
Correct Answer: B
Rationale: A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.
The nurse is caring for a patient following a needle biopsy of the liver at the bedside. Which of the following actions should the nurse implement?
- A. Put pressure on the biopsy site using a sandbag.
- B. Elevate the head of the bed to facilitate breathing.
- C. Place the patient on the right side with the bed flat.
- D. Check the patient's post-biopsy coagulation studies.
Correct Answer: C
Rationale: After a biopsy, the patient lies on the right side for a minimum of two hours with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.
The nurse is listening to a patient's abdomen. Which of the following findings indicate a need for a focused abdominal assessment?
- A. Loud gurgles
- B. High-pitched gurgles
- C. Absent bowel sounds
- D. Frequent clicking sounds
Correct Answer: C
Rationale: Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.