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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.
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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.
The nurse is preparing to assess a patient's liver. When palpating the liver, which of the following techniques should the nurse implement?
- A. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin.
- B. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge.
- C. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt.
- D. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.
Correct Answer: A
Rationale: The liver is normally not palpable below the costal margin, the nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.
The nurse is caring for a patient who has just had a colonoscopy. Which of the following symptoms should alert the nurse that a perforation has occurred?
- A. Malaise
- B. Abdominal distension
- C. Hypertension
- D. Bradycardia
- E. Tenesmus
Correct Answer: A,B,E
Rationale: Following a colonoscopy the nurse should observe the patient for rectal bleeding and signs of perforation (e.g. malaise, abdominal distension, tenesmus). Hypertension and bradycardia are not typical signs of perforation.
Which of the following information obtained by the nurse when admitting a patient who is scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?
- A. The patient has a permanent gastrostomy tube.
- B. The patient took a laxative the previous evening.
- C. The patient ate a low-fat bagel an hour previously.
- D. The patient had a high-fat meal the previous evening.
Correct Answer: C
Rationale: Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8-12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
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.