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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Normal finding: This is not a normal finding. Dullness in this area could indicate an enlarged liver (hepatomegaly), which requires further evaluation.

B. Enlarged liver: Dullness above the right costal margin, especially around 11 cm, is often associated with hepatomegaly. The nurse should refer the patient to a physician for further investigation.

C. Hepatomegaly: While the finding could suggest hepatomegaly, the diagnosis should be confirmed by a physician. The nurse should refer the patient for further evaluation.

D. Alcohol intake: While it is relevant to ask about alcohol intake in the context of liver health, the immediate action is to refer the patient for further examination by a physician.

A. 1 minute B. 2 minutes each quadrant C. 5 minutes D. 10 minutes

Correct Answer is B

Explanation

A. 1 minute: This is not the correct duration for assessing bowel sounds.

B. 2 minutes each quadrant: Bowel sounds should be auscultated for at least 2 minutes per quadrant before determining that they are absent.

C. 5 minutes: Listening for 5 minutes is excessive and typically unnecessary unless there is concern about a complete absence of bowel sounds.

D. 10 minutes: 10 minutes is also too long for auscultation unless specifically indicated by clinical findings, like suspected paralytic ileus.

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During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?

Correct Answer is B

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is B

Explanation

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