A nurse is collecting data from a patient who has dehydration. Which findings should the nurse expect?

Bradycardia

Bounding radial pulse

Urine output of 20mL/hr

Cool skin

Answer and Explanation

The Correct Answer is D

A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.

B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.

C. Inspection – Inspection is visual observation, not a tactile assessment.

D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.

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Correct Answer is A

Explanation

A. Prevent distortion of bowel sounds. – Palpation can stimulate peristalsis and alter bowel sounds, leading to inaccurate assessment findings.

B. Prevent distortion of vascular sounds. – While palpation might affect vascular sounds slightly, this is not the primary concern when assessing the abdomen.

C. Determine any areas of tenderness or pain. – While assessing for tenderness is important, auscultation precedes palpation primarily to avoid altering bowel sounds.

D. Allow the patient to relax and be comfortable. – While relaxation is beneficial, the sequence of assessment is based on maintaining accuracy in findings rather than patient comfort.

A. 30 seconds to 1 minute B. 10-15 seconds C. 20 seconds D. 2-5 minutes

Correct Answer is D

Explanation

A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.

B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.

C. 20 seconds. – This time frame is associated with 3+ pitting edema.

D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.

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A nurse is collecting data from a patient who has dehydration. Which findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

The main reason that auscultation precedes palpation of the abdomen is to:

Correct Answer is A

Explanation

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

Correct Answer is D

Explanation

The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

The profuse secretion of sweat associated with an elevated body temperature, certain disease conditions, physical exertion, exposure to heat and mental or emotional stress is termed:

An abnormally slow heart rate, below 60 beats per minute is called:

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

A nurse is collecting data from a patient who has dehydration. Which findings should the nurse expect?

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The study of all factors involved in the development of the disease or the cause of the disease is termed:

The most frequently used skill in the physical nursing assessment is: