A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?
Palpation of the patient's lymph nodes
Auscultation of the patient's apical heart rate
Palpation of the patient's liver
Percussion of the patient's abdomen
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1: Determine the desired dose in mL.
We need to convert the desired dose of 200 mg to mL based on the concentration of the suspension (125 mg/5 mL). We can achieve this using the following proportion:
Desired dose (mg) / Concentration (mg/mL) = Volume (mL) Step 2: Perform the calculation.
Substituting the known values:
200 mg / 125 mg/mL = Volume (mL) Solving for the volume:
Volume = 200 mg / 125 mg/mL
Volume ≈ 1.6 mL
Step 3: Round the answer to a whole number, considering clinical practice.
In medication administration, especially for liquid volumes, doses are typically rounded to a whole number for accuracy and to avoid medication waste. Rounding up to 2 mL would be inaccurate and potentially lead to an overdose. Therefore, we round down to the nearest whole number, which is 1 mL.
Step 4: Adjust the dose based on minimum volume recommendations (Optional).
Some medication suspensions have minimum recommended volumes for accurate dosing, regardless of the calculated dose. Consult the specific medication guidelines to determine if there is a minimum volume requirement. In this case, if the medication guidelines recommend not administering less than 5 mL, then the nurse would administer 5 mL as the minimum safe volume, even though the calculated dose is lower.
Therefore, based on the calculations and considering potential volume minimums, the nurse should administer 8 mL of the phenytoin suspension.
Correct Answer is ["033"]
Explanation
Step 1 is to calculate the number of milliliters (mL) that contain the ordered dose of 300 mg of clindamycin.
Step 2 is to divide the total milliliters (mL) from Step 1 by the infusion time in minutes to get the flow rate in mL/hour. Here are the calculations:
Step 1:
900 mg of clindamycin is in 50 mL.
To find the mL that contain 300 mg, set up a proportion:
(300 mg / 900 mg) = (x mL / 50 mL) Cross-multiply and solve for x:
x = (300 mg * 50 mL) / 900 mg x = 16.67 mL
Step 2:
The infusion time is 30 minutes.
Divide the total mL (16.67 mL) by the infusion time in hours to get the flow rate in mL/hour: Flow rate = 16.67 mL / (30 minutes / 60 minutes/hour)
Flow rate = 33.33 mL/hour
Round to the nearest whole number, using a leading zero if it applies, and no trailing zero: Flow rate = 033 mL/hour
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