A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
Polyuria
Peripheral edema
Decreased respirations
Absent bowel sounds
The Correct Answer is D
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Given:
Diphenhydramine syrup: 12.5 mg/5 MLX
Required dose: 25 mg
First, determine the ratio of the available dosage strength to the required dose:
12.5 mg (available dose) / 5 mL (volume) = 25 mg (required dose) / X mL
Cross-multiply to find X (the amount of syrup needed):
12.5 mg X mL = 25 mg 5 mL
Now, solve for X:
X = (25 mg 5 mL) / 12.5 mg
X = 125 / 12.5
X = 10
Therefore, the nurse should administer 10 mL of diphenhydramine syrup to provide a dose of 25 mg to the older adult client with rhinitis.
Correct Answer is A
Explanation
Choice A Reason:
Checking the client for ecchymosis is appropriate. Thrombocytopenia increases the risk of bleeding and bruising, so monitoring for ecchymosis (bruising) is essential to detect any signs of bleeding. Ecchymosis can occur more easily in individuals with low platelet counts.
Choice B Reason:
Initiating protective isolation for the client is typically unnecessary solely due to thrombocytopenia. Protective isolation is generally for clients with conditions that compromise their immune system or make them more susceptible to infections.
Choice C Reason:
Administering ibuprofen for a mild headache might not be advisable in someone with thrombocytopenia because ibuprofen can affect platelet function and potentially increase the risk of bleeding.
Choice D Reason:
Instructing the client to shave with a disposable razor isn't recommended because using a sharp blade can increase the risk of cuts and bleeding in someone with a low platelet count. Using an electric razor or avoiding shaving might be safer options to prevent injury and bleeding.
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