A pediatric nurse palpates a 2-year-old child's liver at 4 cm below the right costal margin. Which actions by the nurse are appropriate? (Select all that apply.)
A.
Assess work of breathing.
B.
Auscultate lung sounds.
C.
Calculate child's intake and output.
D.
Determine last bowel movement.
E.
Listen for heart murmur.
ANS: A, B, C, D
An enlarged liver in a child can be indicative of heart failure or fluid overload from congenital heart defects. Assessing for respiratory distress, listening to heart and lung sounds, and calculating I&O will all give information related to cardiac function. Bowel movements are not related.
You might also like to view...
A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.
A patient with a bacterial infection has been placed on antibacterial therapy. Which assessment finding in the patient indicates that the therapy is effective?
a. Red blood cell count is 4,500,000 cells/mm3. b. White blood cell (WBC) count is 8000 cells/mm3. c. Wound drainage is thick and yellow. d. Temperature is 102.4° F.
Which statement is most accurate regarding nursing students and the legal responsibilities they incur?
a. They do not need to have professional lia-bility insurance. b. They can perform any skill, even if they have not been taught that skill in nursing skills laboratory. c. They are accountable for all actions they perform. d. They practice on the license of their in-structors.
A patient is brought to the Emergency Department with cold, white, waxy fingers and toes. The patient denies pain. Which intervention does the healthcare professional provide as the priority?
a. Applying local, dry heat b. Rubbing or massaging the area c. Immersing in warm water d. Leaving the area uncovered