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Which of the following sounds should the nurse expect to hear when percussing a distended bladder?
- A. Hyperresonance.
- B. Tympany.
- C. Dullness.
- D. Flatness.
Correct Answer: C
Rationale: A distended bladder produces a dull percussion sound due to its fluid-filled nature, unlike the resonant or tympanic sounds of air-filled structures.
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A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first:
- A. Assess the airway.
- B. Administer oxygen.
- C. Apply pressure to the site.
- D. Assess the pulse in the left extremity.
Correct Answer: C
Rationale: Applying pressure to the site controls bleeding, which is the priority in this scenario.
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
- A. Irrigate the tube with 30 mL of sterile saline every 4 hours.
- B. Keep the head of the bed elevated at 45 degrees.
- C. Check for tube placement every shift.
- D. Clamp the tube when ambulating the client.
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
The nurse instructs a female client about collecting a midstream urine sample for culture and sensitivity. Which should the nurse include in client teaching?
- A. Bathe before collecting the specimen.
- B. Cleanse the perineum from front to back.
- C. Label specimen with the provider's name.
- D. Collect urine at the beginning of urination.
Correct Answer: B
Rationale: To prepare properly for collection of a sterile urine specimen, the client cleanses the perineum from front to back using antiseptic swabs. Bathing before a midstream urine collection is unnecessary; however, proper specimen handling is critically important because improper specimen handling can yield inaccurate test results. The specimen should be labeled with the client's name, date, time, and medical record number in addition to the provider's name. The client should begin the flow of urine and collect the sample after starting the flow of urine, and then send the specimen to the laboratory as soon as possible.