The nurse is reviewing the physician's notes on a patient's chart. The nurse notes that the patient demonstrated Cullen sign. The nurse correctly recognizes that this patient most likely had which manifestation?
a. Sharp flank pain
b. Pain in the upper right quadrant of the abdomen
c. Pain with inspiration
d. A bluish tinge around the umbilicus
D
Cullen sign refers to a bluish tinge around the umbilicus. It may be noted in the presence of in-ternal abdominal hemorrhage.
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During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure?
a. "I have to sleep in my recliner and I have this hacking cough." b. "I have no appetite and I have lost 3 lb in the last week." c. "I have to urinate every 2 hours, even during the night." d. "I go barefoot most of the time because my feet are so hot."
A patient answers "yes" to the nurse's question, "In the past year, have you been hit, kicked, punched, or hurt in other ways by someone close to you?" What next nursing intervention is most important?
a. Conduct a physical exam to assess for signs/symptoms of suspected violence and abuse. b. Report the suspected violence and abuse to the appropriate state agency. c. Ask the patient if she feels safe in her current environment or situation. d. Document physical findings concisely and accurately.
When assessing for Tinel's sign in a patient with possible right-sided carpal tunnel syndrome, the nurse will ask the patient about
a. weakness in the right little finger. b. tingling in the right thumb and fingers. c. burning in the right elbow and forearm. d. tremor when gripping with the right hand.
MC Select the true statements related to airway insertion. (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected
A. Oropharyngeal airways are initially turned upside down for insertion. B. Only the tip of the nasopharyngeal airway is lubricated prior to insertion. C. Clients are placed in a semi-Fowler's position for endotracheal intubation. D. Breath sounds are assessed following endotracheal intubation. E. Sterile technique is used in cleaning and suctioning the new tracheostomy tube.