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Questions 149

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Question 1 of 5

The nurse is assessing for abdominal pulsations in a client with a visible mass below the umbilicus. The nurse should use which technique?

Correct Answer: B

Rationale: Inspection is used to visually assess for abdominal pulsations or masses. Palpation or percussion may be used later but are not the initial technique for observing pulsations.

Question 2 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.

Question 3 of 5

The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

Correct Answer: A

Rationale: Cleansing the eye removes exudate, ensuring effective administration of eyedrops for conjunctivitis.

Question 4 of 5

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

Correct Answer: A

Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.

Question 5 of 5

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

Correct Answer: C

Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.

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