Nokea
The nurse performs palpation and percussion during a head-to-toe assessment. Over which organ would the nurse expect to hear tympany when percussed?
- A. Stomach
- B. Liver
- C. Normal lung tissue
- D. Tympany is an abnormal finding
Correct Answer: A
Rationale: Tympany, a hollow sound, is expected over the stomach due to air in the gastric bubble. Liver produces dullness, lungs produce resonance, and tympany is normal in certain areas.
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The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Implement seizure precautions
- C. Read back the result for verification
- D. Recollect the laboratory specimen
Correct Answer: C
Rationale: Reading back the critical result verifies accuracy, the first step before further action. Notifying the provider, seizure precautions, or recollecting follow verification.
The nurse needs to assess the use of complementary and alternative medicine (CAM) because:
- A. Patients should be warned that most CAM therapies are potentially dangerous
- B. Additional treatment may not be needed if the patient is using CAM
- C. CAM therapy could interact with prescription and over-the-counter medications
- D. Most CAM therapies are essentially ineffective
Correct Answer: C
Rationale: CAM therapies can interact with medications, affecting efficacy or safety. Not all CAM is dangerous, ineffective, or a replacement for conventional treatment.
The nurse is observing a student prepare to perform a sterile procedure. Which action by the student would require follow-up? The student
- A. reaches over the sterile field to grab sterile gloves.
- B. establishes the sterile field on a dry surface.
- C. uses slow movements when setting up sterile drapes.
- D. keeps the sterile field at their waist level.
Correct Answer: A
Rationale: Reaching over the sterile field risks contamination and requires follow-up.
The nurse is reviewing the assessment findings of a 5-year-old child. The nurse recognizes which vital sign is not within normal limits?
- A. Pulse 73
- B. Blood pressure 90/60 mmHg
- C. Respiratory rate 24
- D. Temperature 98.6°F (37°C)
Correct Answer: C
Rationale: A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits.
The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.