A client's bladder is found to be distended. At which location would the nurse begin palpating?

At the symphysis pubis.

In the left lower quadrant.

At the umbilicus.

In the right lower quadrant.

Answer and Explanation

The Correct Answer is A

A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.

B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.

C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.

D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.

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Correct Answer is C

Explanation

A. 20: Incorrect, as it would imply a much higher dose.

B. 0.2: Incorrect, as this would be far too low.

C. 2: Phenytoin 0.2 g is equivalent to 200 mg (0.2 g x 1000 mg/g). Since each capsule is 100 mg, the nurse would need to administer 2 capsules (200 mg / 100 mg per capsule = 2).

D. 200: Incorrect, as 200 capsules would be an overdose.

A. Intake and output B. Daily weight C. Sodium level D. Skin tenting

Correct Answer is B

Explanation

A. Intake and output: Although helpful, intake and output measurements can sometimes be inaccurate, as not all fluid retention may be recorded.

B. Daily weight: Daily weight measurements are the most reliable way to assess fluid retention because changes in body weight accurately reflect gains or losses in body fluid, especially in clients with chronic kidney disease.

C. Sodium level: Sodium levels can indicate fluid imbalances, but they do not directly measure fluid volume excess.

D. Skin tenting: Skin tenting is used to assess dehydration, not fluid retention, and is not a reliable measure in chronic kidney disease.

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A client's bladder is found to be distended. At which location would the nurse begin palpating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives the primary provider's order of phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer. (Round to the nearest whole number)

Correct Answer is C

Explanation

A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

Correct Answer is B

Explanation

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