A nurse is collecting data from a client who is African American has cholecystitis. Which of the following areas should the nurse inspect to monitor for the presence of jaundice?
Webbed areas of the fingers
Nail beds
Hard palate
Peri-umbilical area
The Correct Answer is C
A. Jaundice is typically not visible in the webbed areas of the fingers.
B. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
C. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
D. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While draping is essential for maintaining sterility, it's typically done right before the physician performs the biopsy, not as a primary pre-procedure step for the nurse.
B. Monitoring for bleeding is important after the procedure, not necessarily beforehand.
C. Although informing the family can be helpful, the patient's understanding and consent are the top priority. Pain management is crucial for patient comfort and cooperation during the procedure.
D. Administering an analgesic helps reduce the patient's anxiety and discomfort during the bone marrow biopsy, which can be a painful procedure. This improves patient tolerance and allows the physician to perform the procedure more efficiently.
Correct Answer is B
Explanation
A. Atrial fibrillation is characterized by rapid, irregular electrical impulses originating from the atria, resulting in a quivering or fibrillating motion of the atria rather than a coordinated contraction.
B. Asystole is the absence of any electrical activity on the cardiac monitor, resulting in a flat line. It indicates the absence of ventricular contraction and is considered a medical emergency requiring immediate intervention (CPR and advanced cardiac life support).
C. Ventricular fibrillation is characterized by chaotic, disorganized electrical activity in the ventricles, resulting in ineffective quivering of the ventricles and loss of cardiac output.
D. Atrial flutter is characterized by rapid but regular electrical impulses originating from the atria, resulting in a sawtooth pattern on the ECG tracing.
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