Nokea
The nurse is reviewing a client's medical record, and it is noted that they have a positive Murphy sign. The nurse recognizes that this sign is elicited in which abdominal quadrant?
- A. Area A
- B. Area B
- C. Area C
- D. Area D
Correct Answer: C
Rationale: Murphy's sign, elicited by pain on palpation of the right upper quadrant (Area C) during inspiration, is associated with cholecystitis.
You may also like to solve these questions
The nurse is caring for a client who is postprocedure following an endoscopy. Which priority action should the nurse take prior to resuming the client's diet?
- A. Assess the client's oxygenation level
- B. Assess for the return of the client's gag reflex
- C. Have the healthcare provider speak with the client regarding results of the procedure
- D. Start with a soft diet to see if the client will tolerate
Correct Answer: B
Rationale: Assessing the gag reflex (B) ensures safe swallowing post-endoscopy to prevent aspiration before resuming the diet.
A nurse is caring for a client diagnosed with a duodenal ulcer. Which medication facilitates healing by forming a protective lining over the client's ulcer?
- A. Famotidine
- B. Omeprazole
- C. Sucralfate
- D. Cimetidine
Correct Answer: C
Rationale: Sucralfate (C) forms a protective barrier over the ulcer, promoting healing by shielding it from stomach acid. Famotidine (A) and cimetidine (D) are H2 blockers, and omeprazole (B) is a proton pump inhibitor, which reduce acid but do not form a physical barrier.
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
- A. Leukocytosis
- B. Melena
- C. Fever
- D. Nausea and Vomiting
- E. Anorexia
Correct Answer: A,C,D,E
Rationale: Appendicitis commonly presents with leukocytosis (A) due to infection, fever (C) from inflammation, nausea and vomiting (D), and anorexia (E) due to gastrointestinal irritation. Melena (B) is not typically associated with appendicitis.
The health care provider (HCP) places an order to administer gentamicin intravenously to a client with acute diverticulitis. It is important the nurse knows that intravenous gentamicin is administered:
- A. Over one minute via IV push
- B. Over two minutes via IV push
- C. As an IV infusion over 15-20 minutes
- D. As an IV infusion over 30 minutes to two hours
Correct Answer: D
Rationale: Gentamicin (D) is administered as an IV infusion over 30 minutes to two hours to ensure safe delivery and minimize toxicity risks like nephrotoxicity.
The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply.
- A. Empties the pouch when it is one-third to one-half full.
- B. Washes the surrounding skin with moisturizing soap.
- C. Indicates that the reddish appearance of the stoma as normal.
- D. Applies sterile gloves prior to changing the device.
- E. Applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.
Correct Answer: B,D,E
Rationale: Using moisturizing soap (B) can interfere with appliance adhesion, sterile gloves (D) are unnecessary as clean gloves suffice, and isopropyl alcohol (E) can irritate the skin. Emptying the pouch appropriately (A) and recognizing a normal stoma (C) are correct.