During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. The nurse should suspect injury to which of the following organs?
1. Kidney
2. Ribs
3. Intestines
4. Bladder
1
Rationale 1: The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3, also termed the costovertebral angle; therefore, a hematoma in this area should alert the nurse to the possibility of injury to the kidney.
Rationale 2: The ribs encompass a larger area than just the costovertebral angle.
Rationale 3: The intestine does not lie at the costovertebral angle.
Rationale 4: The bladder does not lie at the costovertebral angle.
You might also like to view...
The nurse accepts the newborn in the delivery room and performs an Apgar assessment at one minute of life. The infant is crying vigorously, has a heart rate of 160, is actively moving all extremities, and has blue hands and feet
The nurse scores the infant as an Apgar of: 1. 6. 2. 7. 3. 8. 4. 9.
The nurse describes two variations on the oral medication route as:(Select all that apply) Standard Text: Select all that apply
1. Nasogastric 2. Buccal 3. Lingual 4. Sublingual 5. Intradermal
The nurse is assigned to a client with insulin-dependent diabetes who was brought to the emergency department because of shortness of breath and confusion. On admission, the client's blood glucose level is 720 mg/ml, and ABG values are pH of 7
28, PaCO2 of 35 mm Hg, and bi-carbonate level of 15 mEq/L. The nurse interprets these readings as indicating a. compensated metabolic acidosis. b. compensated respiratory acidosis. c. uncompensated metabolic acidosis. d. uncompensated respiratory acidosis.
The nurse is assessing for skin changes in an older woman. Which findings require immediate referral? (Select all that apply.)
a. Excessive moisture under axilla b. Increased hair thinning c. Increased presence of fungal toenails d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead