A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

Gurgling bowel sounds every 10 seconds

Centrally located umbilical protrusion

Abdominal distention during breathing

Rebound tenderness with palpation

Answer and Explanation

The Correct Answer is D

Choice A reason: Gurgling bowel sounds every 10 seconds are considered normal, as normoactive bowel sounds range from 5 to 30 sounds per minute. This finding indicates regular gastrointestinal activity and is not typically a cause for concern.

Choice B reason: A centrally located umbilical protrusion can be a normal finding, especially if it has been present since birth and is not associated with any other symptoms. However, if new or associated with pain or other symptoms, it could indicate a hernia or other pathology.

Choice C reason: Abdominal distention during breathing can be a normal finding, as the abdomen may distend slightly during deep breathing due to the movement of the diaphragm. However, if the distention is pronounced or associated with other symptoms, it may warrant further investigation.

Choice D reason: Rebound tenderness with palpation is a sign of peritoneal irritation and can be an indication of conditions such as appendicitis, which is a surgical emergency. This finding should be considered a priority as it may require immediate intervention.

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Correct Answer is A

Explanation

Choice A reason: Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.

Choice B reason: Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.

Choice C reason: Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.

Choice D reason: Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.

A. Laryngeal edema B. Fever C. Hypertension D. Arrhythmia

Correct Answer is A

Explanation

Choice A reason: Laryngeal edema is a classic sign of anaphylaxis, a severe and potentially life-threatening allergic reaction. It can lead to difficulty breathing and requires immediate medical attention. Anaphylaxis can occur with any medication, including captopril, especially on initial exposure.

Choice B reason: Fever is not typically a sign of anaphylaxis. While it can be a symptom of various infections or inflammatory processes, it is not indicative of an immediate hypersensitivity reaction.

Choice C reason: Hypertension, or high blood pressure, is not a sign of anaphylaxis. In fact, during an anaphylactic reaction, blood pressure often drops significantly, a condition known as anaphylactic shock.

Choice D reason: Arrhythmia, or an irregular heartbeat, can be associated with various cardiac conditions but is not a specific indicator of anaphylaxis. While severe allergic reactions can affect heart rate, they are more likely to cause hypotension than arrhythmia.

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A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

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