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Which of the following assessment findings in a patient who is being admitted to the hospital is most important to report to the health care provider?
- A. Tympany on percussion of the abdomen
- B. Liver edge 3 cm below the costal margin
- C. Bowel sounds of 20/minute in each quadrant
- D. Aortic pulsations visible in the epigastric area
Correct Answer: B
Rationale: Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.
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The nurse is caring for a patient following a needle biopsy of the liver at the bedside. Which of the following actions should the nurse implement?
- A. Put pressure on the biopsy site using a sandbag.
- B. Elevate the head of the bed to facilitate breathing.
- C. Place the patient on the right side with the bed flat.
- D. Check the patient's post-biopsy coagulation studies.
Correct Answer: C
Rationale: After a biopsy, the patient lies on the right side for a minimum of two hours with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.
The health care provider sees a patient at 10 A.M. and writes a prescription for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which of the following actions that are included in the agency protocol for ERCP should the nurse take first?
- A. Place the patient on NPO status.
- B. Administer sedative medications.
- C. Ensure the consent form is signed.
- D. Explain the procedure to the patient.
Correct Answer: A
Rationale: The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
The nurse is obtaining a history from a patient who is admitted with jaundice. Which of the following statements is most indicative of a need for patient teaching?
- A. I used cough syrup several times a day last week.
- B. I take a baby Aspirin every day to prevent strokes.
- C. I need to take an antacid for indigestion several times a week.
- D. I use acetaminophen every 4 hours for persistent pain.
Correct Answer: D
Rationale: Persistent use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.
Which of the following information obtained by the nurse when admitting a patient who is scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?
- A. The patient has a permanent gastrostomy tube.
- B. The patient took a laxative the previous evening.
- C. The patient ate a low-fat bagel an hour previously.
- D. The patient had a high-fat meal the previous evening.
Correct Answer: C
Rationale: Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8-12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
Which of the following actions by a nursing student when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene?
- A. Offering the patient a glass of water
- B. Positioning the patient on the right side
- C. Checking the vital signs every 30 minutes
- D. Swabbing the patient's mouth with cold water
Correct Answer: A
Rationale: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. The patient should be NPO for 2-4 hours. Assessment for return of the gag reflex should be done prior to administering any fluids by mouth. The other actions by the student are appropriate.