The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

a. Dullness
b. Tympany
c. Resonance
d. Hyperresonance


ANS: A
The liver is located in the right upper quadrant and would elicit a dull percussion note.

Nursing

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A patient infected with AIDS tells the nurse that she has been only partially compliant with the medications because of the side effect of nausea. Which is the best response made by the nurse?

a. "When the nausea decreases, you can take the dosage." b. "You should stop all medicine when nauseated and call your doctor." c. "You should always take your medicine as prescribed, or it may not be effective." d. "Didn't you know that nausea is expected with this therapy?"

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A client is being seen at the clinic for the first time, and the nurse asks the client about what brought them to the clinic today as well as the past medical history. What part of the interview process does this represent?

A) Introductory phase B) Working phase C) Summary phase D) Closing phase

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Identify the mechanisms involved in acid–base balance. Select all that apply

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The client who was diagnosed with diabetes mellitus 1 year ago is hospitalized in diabetic ketoacidosis after a religious fast. The client tells the nurse, "I have fasted during this season every year since I became an adult

I am not going to stop now.". The nurse is not knowledgeable about this particular religion. What is the best action for this nurse? 1. Tell the client that it is different now because of the diabetes. 2. Do some research into the meaning of fasting in this religion. 3. Ask family members of the same religion to discuss fasting with the client. 4. Request a consult from a diabetes educator.

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