Which technique should the nurse use to measure the liver span of a client admitted with cirrhosis?
A. Auscultation
B. Percussion
C. Inspection
D. Palpation
B
Although the liver edge can be felt on palpation, percussion is used to determine the span of the liver and other solid organs. The nurse percusses down the midclavicular line below the right nipple until resonance changes to dullness. The nurse marks this area as the upper border of the liver. The nurse then percusses up from the iliac crest in the midclavicular line until the percussion notes change from tympany to dullness, indicating the lower border of the liver. The nurse marks this area and measures the distance between the two marks (the liver span), which is normally 5 to 10 cm.
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Which nursing action should be implemented when performing skin testing?
a. Select an 18-gauge needle. b. Inject 1 mL intradermally. c. Check the site in 2 to 3 days for swelling. d. Wrap the site with a pressure dressing.
The nurse is listening to a client's heart sounds. Which statement is true about systole?
a. At the onset of systole, the pressure in the ventricles is less than that in the atria. b. During this phase, the mitral and tricuspid valves close, producing the first heart sound. c. Blood flows from the atria into the ventricles. d. The atria contract, sending blood into the ventricles.
Which of the following drugs is a derivatives of nitrosourea, yet works by inhibiting microtubule assembly?
A. Carmustine B. Vincristine C. Lomustine D. Estramustine
To help a patient with expressive aphasia communicate, the nurse's most effective intervention would be to:
a. provide flash cards with text and pictures. b. be patient and ask the patient to repeat himself. c. encourage the patient to practice slow speech. d. arrange with the patient to blink the eyes once for "yes" and twice for "no."