How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

A.

Palpation of the patient's lymph nodes

B.

Auscultation of the patient's apical heart rate

C.

Palpation of the patient's liver

D.

Percussion of the patient's abdomen

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

Choice A rationale:
Losing 2 pounds in 2 weeks is not a significant weight loss and may not be a cause for concern in this context. It's important to monitor weight trends over time, but this isolated statement doesn't necessarily require immediate discussion.
Choice B rationale:

Engaging in physical activity like swimming is generally beneficial for individuals with rheumatoid arthritis. It can help improve joint mobility, reduce pain, and enhance overall well-being. The nurse might encourage the client to discuss any specific concerns or limitations with their healthcare provider, but the activity itself is not alarming.
Choice C rationale:
Taking an antibiotic concurrently with naproxen can potentially increase the risk of adverse effects. Some antibiotics, like those in the fluoroquinolone class (e.g., ciprofloxacin, levofloxacin), can interact with naproxen and increase the risk of tendonitis or tendon rupture. This interaction warrants further discussion to ensure the client is aware of potential risks and to explore alternative medications if necessary.
Choice D rationale:
Using applesauce to facilitate medication intake is a common and acceptable practice. It does not affect the absorption or efficacy of naproxen.

Correct Answer is ["1370"]

Explanation

To calculate the total output for the client, we need to add up all the individual outputs:

  • The client voided 400 mL at 1100.
  • The client voided 350 mL at 1430.
  • The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
  • The NG tube has 575 mL in the drainage container.
  • The Jackson-Pratt drainage tube has 25 mL.

Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.

Here’s the calculation:

400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL

So, the nurse should record a total output of 1370 mL in the medical record for the client.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register