The nurse assesses the client admitted with constipation. Which assessment finding warrants further investigation?
1. No aortic bruit
2. Firm liver edge
3. Bowel sounds audible
4. Abdomen round and taut
4
4. A distended abdomen is round and taut and is a significant finding for a client with constipation because it potentially indicates the accumulation of fluid, gas, tumor, or other material, including a fetus. This warrants the nurse's attention because if the accumulation of fluid or gas is due to a bowel obstruction, the client can need emergency care to prevent the bowel from rupturing and spilling intestinal contents into the peritoneum.
1, 2, and 3. Absence of aortic bruits, a firm liver edge, and audible bowel sounds are normal findings.
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The patient is to be catheterized for residual urine. The nurse must perform this catheterization within how many minutes following voiding?
a. 40 minutes b. 30 minutes c. 20 minutes d. 10 minutes
You are auscultating a patient's heart during a routine physical examination. You should position the patient
a. in a flat, supine position or a sitting position. b. in the left lateral position. c. leaning forward slightly. d. on his back with the bed raised 45°.
A nurse is responsible for determining the incidence rates of hospital-acquired diarrhea on a pediatric ward after receiving reports that five children admitted with uncontrolled asthma had developed diarrhea while hospitalized
The nurse is working in the role of: a. quality management. b. infection control. c. occupational health. d. forensics.
Prepare a 250 mg dose from a label reading 500 mg/15 mL
What will be an ideal response?