During an assessment of a patient's abdomen, frequent pulsations are noted in the epigastric region. What action by the nurse is indicated?
1. Document the findings as hyperactive bowel sounds.
2. Review the patient's medical records for signs and symptoms of cirrhosis, which may indicate ascites.
3. Note the time when the patient last voided.
4. Auscultate for a bruit.
4
Rationale 1: Bowel sounds are audible, not visible.
Rationale 2: Ascites is the collection of fluid.
Rationale 3: Bladder distention is not manifested as a pulsation. Bladder distention can be detected by palpation.
Rationale 4: The nurse should carefully listen over this area for a bruit that can be associated with aortic aneurysm.
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After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?
a. "I'll rinse my rectal area with warm water after each stool and apply zinc oxide ointment." b. "I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel." c. "I must take a sitz bath three times a day and then pat my rectal area gently but thoroughly to make sure I am dry." d. "I shall clean my rectal area with a soft cotton washcloth and then apply vitamin A and D ointment."
The nurse needs to insert a small-bore nasointestinal feeding tube. Choose suitable reference points for measuring accurate feeding tube length and place in the correct order
1. Earlobe 2. Umbilicus 3. Add 12 cm 4. Add 20 cm 5. Tip of the nose 6. Xiphoid process
The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? The new nurse:
1. Holds the infant after giving a gavage feeding. 2. Auscultates lung sounds bilaterally. 3. Provides care when the baby is awake. 4. Gives the feeding with room-temperature formula.
The nurse tells the client that the automatic nervous system is divided into the sympathetic and parasympathetic nervous systems. Based on this information, what happens to the vital signs when the sympathetic nervous system is activated?
1 . Tachycardia 2 . Breathing rate normal 3 . Maintains normal body functions 4 . Prepares body for "fight-or-flight" response A) 1, 3 B) 1, 4 C) 2, 3 D) 3, 4