Which technique is most effective for assessing the patient's abdominal organ size?

Correct Answer: B

Rationale: The correct answer is B: Palpation. Palpation is the most effective technique for assessing the patient's abdominal organ size as it allows the healthcare provider to feel and evaluate the size, texture, and consistency of the abdominal organs through touch. This hands-on approach provides valuable information about any abnormalities or tenderness in the organs. Inspection (choice A) involves looking at the abdomen for any visible signs but does not provide information on organ size. Percussion (choice C) involves tapping on the abdomen to assess the density of underlying structures, not specifically organ size. Auscultation (choice D) involves listening to sounds within the abdomen and does not directly assess organ size. Palpation is the preferred method for accurately assessing abdominal organ size due to its tactile nature.

Correct Answer: B

Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.

Correct Answer: C

Rationale: The correct answer is C: Glucose. Total Parenteral Nutrition (TPN) is a form of nutrition delivered directly into the bloodstream, providing all essential nutrients including glucose. Monitoring glucose levels is crucial to prevent hyperglycemia or hypoglycemia. Calcium (A), Magnesium (B), and Cholesterol (D) are not typically monitored closely when a client is on TPN, as they are not directly impacted by TPN administration. Calcium and Magnesium levels are usually monitored for other conditions, and Cholesterol levels are not typically affected by TPN administration.

Correct Answer: B

Rationale: The correct answer is B: Chronic obstructive pulmonary disease (COPD). The patient's history of smoking, persistent cough, and worsening symptoms over months are indicative of COPD, a progressive lung disease commonly caused by smoking. Asthma (A) typically presents with intermittent symptoms, bronchitis (C) may cause cough but not necessarily worsening over time, and pulmonary embolism (D) is characterized by sudden onset symptoms and is less likely in this case. COPD is the most concerning due to the patient's smoking history and progressive symptoms.

Correct Answer: C

Rationale: The correct answer is C: Mental. Nursing assessments typically include physical, focused, and emergency assessments. Mental assessments are more commonly associated with psychiatric nursing rather than general nursing assessments. Mental assessments focus on assessing a patient's mental status, emotions, and cognitive functions, which are not typically part of routine nursing assessments. Therefore, mental assessments do not fall under the types of assessments typically performed by general nurses.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.

Correct Answer: A

Rationale: Rationale for Correct Answer A: 1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth. 2. This method helps to preserve the nutrients in the breast milk or formula. 3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort. Summary of Incorrect Choices: B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness. C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby. D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.