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The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
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The nurse is caring for a client with a hiatal hernia who is being discharged today. The nurse talks to them regarding methods to manage symptoms and promote overall well-being associated with their condition. Which of the following statements from the client indicate that teaching is successful?
- A. I need to wear loose-fitting clothes.
- B. After a meal, I must lie down to avoid dumping syndrome.
- C. I need to eat three large meals a day.
- D. I can go to my favorite Indian restaurant anytime of the week.
Correct Answer: A
Rationale: Wearing loose-fitting clothes (A) reduces pressure on the stomach, helping manage hiatal hernia symptoms. Lying down after meals (B) can worsen reflux, large meals (C) increase symptoms, and spicy foods (D) may exacerbate reflux.
The nurse supervises a student nurse giving medications through a nasogastric tube (NGT) to a client receiving continuous enteral feeding. Which actions by the student require follow-up by the nurse? Select all that apply.
- A. Gives each medication separately
- B. Verifies placement of the NGT prior to medication administration
- C. Elevates the head of the bed to 15 degrees
- D. Adds crushed medications directly to a tube feeding
- E. Crushes each tablet into a fine powder
Correct Answer: C,D
Rationale: Elevating the head of the bed to only 15 degrees (C) is insufficient to prevent aspiration; 30-45 degrees is recommended. Adding crushed medications to the tube feeding (D) can clog the tube or alter medication efficacy. Other actions (A, B, E) are correct.
The nurse is assessing a client diagnosed with necrotizing pancreatitis. Which of the following assessment findings would be expected?
- A. Ecchymotic discoloration in the periumbilical region
- B. Dysuria
- C. Hyperactive bowel sounds
- D. Hematuria
Correct Answer: A
Rationale: Ecchymotic discoloration in the periumbilical region (A), known as Cullen's sign, is expected in necrotizing pancreatitis due to retroperitoneal hemorrhage.
The nurse has taught a client scheduled for a liver biopsy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will not be conscious during this procedure.
- B. I should not take any acetaminophen one week before this procedure.
- C. I will need to cough and deep breathe every two hours after this procedure.
- D. I may be asked to hold my breath during the insertion of the biopsy needle.
Correct Answer: D
Rationale: Holding the breath (D) during needle insertion stabilizes the liver, reducing complications. The procedure is typically done under local anesthesia (A is incorrect), acetaminophen restriction (B) is not standard, and coughing (C) is not required post-procedure.
The nurse in the intensive care unit is caring for a client being treated for necrotizing pancreatitis. Which of the following findings would indicate the client is experiencing a complication?
- A. Periumbilical bruising
- B. Abdominal pain rated 5/10 on the numerical rating scale
- C. White blood cell count 13,500 mm3 [5,000-10,000 mm3]
- D. Decreased lung sounds in the left lower lung fields
Correct Answer: D
Rationale: Decreased lung sounds (D) may indicate a complication like pleural effusion or atelectasis in necrotizing pancreatitis, requiring further evaluation.