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The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
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Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
- A. Head elevated to 45 degrees
- B. Have the patient lie flat
- C. Place the patient in the supine position
- D. Position the patient on their side
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
- A. I should limit my intake of foods high in potassium and phosphorus.
- B. I should increase my fluid intake to stay hydrated.
- C. I can eat as much protein as I want to promote healing.
- D. I should drink more sodas for hydration.
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients. Therefore, option A is the best choice for proper understanding of dietary changes in CKD.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
- A. Jaundice.
- B. Hypoglycemia.
- C. Hyperglycemia.
- D. Anemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease.
B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely.
C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication.
D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse prioritize?
- A. Administering diuretics.
- B. Providing supplemental oxygen.
- C. Increasing fluid intake.
- D. Encouraging bed rest.
Correct Answer: B
Rationale: The correct answer is B: Providing supplemental oxygen. In COPD, patients often have difficulty breathing due to impaired lung function. Supplemental oxygen helps improve oxygenation and relieves respiratory distress. Prioritizing this intervention is crucial for managing COPD exacerbations and preventing complications. Administering diuretics (A) may be indicated for comorbid conditions like heart failure but is not a priority in managing COPD. Increasing fluid intake (C) may not directly address the patient's respiratory distress. Encouraging bed rest (D) may lead to deconditioning and worsen respiratory function in COPD patients.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Respiratory failure.
- C. Hyperkalemia.
- D. Anemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.