The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment?
1. Loud, low-pitched.
2. Soft, high-pitched.
3. Drum-like.
4. Abnormally loud.
Correct Answer: 3
Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. Resonance is a loud, low-pitched tone of normal findings over the lungs. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.
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A patient in the intensive care unit has a pulmonary artery catheter for hemodynamic monitoring. On assessment, the nurse finds the patient clinically unchanged from the last assessment, but the hemodynamic data are significantly changed
Which action by the nurse is the most appropriate? A. Document the findings and continue to monitor. B. Level and recalibrate the hemodynamic line. C. Notify the health-care provider of the findings. D. Review the last set of laboratory data for any changes.
A patient was prescribed an oral antibiotic for the treatment of sinusitis. The patient has now stopped, stating she developed a rash shortly after taking the first dose of the drug. What is the nurse's most appropriate response?
A) Encourage the woman to continue with the medication while monitoring her skin condition closely. B) Refer the woman to her primary care provider to have the medication changed. C) Arrange for the woman to go to the nearest emergency department. D) Encourage the woman to take an OTC antihistamine with each dose of the antibiotic.
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
A) Sight morning discharge from the eye B) Mild redness of the eye C) Scratchy feeling in the eye D) New floater in vision
The nurse is participating in an educational program concerning nuclear disasters. Which factor(s) determine(s) a victim's level of exposure to radiation? (Select all that apply.)
a. Age of the victim b. Body surface area of the victim c. Length of exposure d. Distance of the victim from the nuclear source e. Shielding of the victim from the nuclear source