During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?
Constipation
Splenomegaly
Distended bladder
Ascites
The Correct Answer is D
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.
B. Referral is not needed if perfusion is adequate.
C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.
D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.
Correct Answer is B
Explanation
A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.
B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.
C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.
D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.
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