Nokea
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
- A. It is less painful for the client.
- B. Palpation and percussion can increase peristalsis.
- C. It identifies any potential areas of abdominal tenderness.
- D. It gives the client more time to become comfortable with the examiner.
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
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The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?
- A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
- B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
- C. The client mixes each medication separately in warm water.
- D. The client mixes their medications with their tube-feeding formula.
Correct Answer: D
Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.
When inspecting the ears for cerumen impaction, the nurse checks for which finding?
- A. Redness and swelling of the tympanic membrane
- B. An external auditory canal that is longer than normal
- C. The presence of edema in the external auditory canal
- D. A yellowish or brownish waxy material in the external auditory canal
Correct Answer: D
Rationale: When inspecting the ears for cerumen impaction, the nurse should look for a yellowish or brownish waxy material in the external auditory canal. Cerumen, also known as ear wax, is a secretion that can become impacted due to various reasons. It is produced by the vestigial apocrine sweat glands in the external ear canal. Cerumen may partially obscure the eardrum or totally occlude the ear canal. The other options, redness and swelling of the tympanic membrane, an external auditory canal that is longer than normal, and the presence of edema in the external auditory canal, are not indicative findings of cerumen impaction.
A healthcare professional reviewing a client's health care record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the healthcare professional determine that the client has?
- A. Scoliosis
- B. Osteoarthritis
- C. Rotator cuff lesions
- D. Carpal tunnel syndrome
Correct Answer: B
Rationale: The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
- A. Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse.'
- B. Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse.'
- C. The average time it takes someone your age to conceive is 5-12 months, so if you haven't conceived by then, we can refer you.'
- D. We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year.'
Correct Answer: D
Rationale: The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice 1 is technically correct, but it doesn't consider the immediate need for the couple to have some counseling. Choice 4 is the best answer because it gives the couple guidance now and the referral at the appropriate time. If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate. It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice 4 is still the most caring and correct answer. Couples conceive within the first month of unprotected intercourse 20% of the time.
How should a nurse listen to the breath sounds of a client?
- A. Ask the client to lie prone.
- B. Ask the client to breathe in and out through the nose.
- C. Hold the bell of the stethoscope lightly against the chest.
- D. Listen for at least one full respiration in each location on the chest.
Correct Answer: D
Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.