Nokea
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.
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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.
The nurse is obtaining a history from a patient who is admitted with jaundice. Which of the following statements is most indicative of a need for patient teaching?
- A. I used cough syrup several times a day last week.
- B. I take a baby Aspirin every day to prevent strokes.
- C. I need to take an antacid for indigestion several times a week.
- D. I use acetaminophen every 4 hours for persistent pain.
Correct Answer: D
Rationale: Persistent use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.
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.
Which of the following information collected by the nurse when caring for a patient who has just arrived in the recovery area after an esophagogastroduodenoscopy (EGD) is most important to communicate to the health care provider?
- A. The patient is very sleepy.
- B. The oral temperature is 38.7°C (101.7°F).
- C. The apical pulse is 104 beats/minute.
- D. The patient complains of a sore throat.
Correct Answer: B
Rationale: A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.
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.