A student is performing a physical assessment on a patient. While assessing the abdomen, the student percusses the spleen. What sound would be normal for the student to hear?
A) Tympany
B) Dullness
C) Hollow sound
D) Friction rub
A
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The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first?
a. Notify the physician. b. Assess for a blood return. c. Document the finding. d. Stop the IV infusion.
A patient is starting on the drug cromolyn
sodium. Which statement made by the patient indicates a need for clarification about the purpose, administration schedule, or side effects of this drug? a. "If I get a skin rash, I will call my doctor right away." b. "I will keep using the drug even if I don't notice a difference in my asthma after the first week." c. "I will keep the inhaler with me at all times so that I can use it quickly when an asthma attack occurs." d. "I have been trying to inhale deeply when I trigger the inhaler so that more of the drug reaches my lungs."
The client has a cast extending from just below the left knee to the toes. Which clinical indicator is evidence supporting a desirable outcome statement that the nurse includes in the client's plan of care?
1. Bilateral pink toes 2. Cast warm at ankle 3. Left foot paresthesias 4. Cast quite snug at knee
The nurse is admitting a client who was diagnosed with hydramnios. The client asks why she has developed this condition. The nurse should explain that hydramnios is sometimes associated with: (Select all that apply.) Select all that apply
1. Chest pain, dyspnea, tachycardia, and hypotension. 2. Postmaturity syndrome. 3. Renal malformation or dysfunction. 4. Maternal diabetes. 5. Large for gestational age infants.