During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
a. Spleen
b. Sigmoid
c. Appendix
d. Gallbladder
ANS: C
The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant.
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A patient who is recovering from cardiovascular surgery is demonstrating chest tube output of greater than 100 mL per hour
Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Report to the surgeon. 2. Check the hemoglobin and hematocrit. 3. Administer a blood transfusion. 4. Notify the family. 5. Connect pacemaker wires.
The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which of the following should the nurse plan to do while caring for this patient?
1. adjust the rate of infusion according to the blood glucose level 2. check blood glucose levels every 2 hours 3. monitor serum calcium levels closely 4. check urine for ketone bodies every shift
Adrenergic drugs mimic the action of the sympathetic nervous system. Which of the following is a response of the sympathetic nervous system?
a. decreased heart rate b. contraction of the pupils c. open the airway d. increased motility and tone of the GI tract
During the implementation phase of the nursing process for medication administration, which procedure is considered essential?
a. Monitor the patient's response to the drug therapy b. Following the five rights of medication administration c. Establishing measurable and realistic outcomes d. Use NANDA nursing dagnoses to plan care delivery