The nurse is percussing a client’s abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider

Document the presence of hepatomegaly

Ask additional health history questions regarding alcohol intake

Recognizes this finding as normal, and proceed with the examination

Answer and Explanation

The Correct Answer is D

Choice A rationale: The normal liver span is 6-12 cm above the right coastal margin hence this finding is normal.

Choice B rationale: This finding is normal and does not indicate hepatomegaly.

Choice C rationale: Additional health history questions regarding alcohol intake may not be relevant in this case since the patient has a normal liver span.

Choice D rationale: The normal liver span in the midclavicular line is 6 to 12 cm, so an area of dullness of 11 cm above the right costal margin is within the normal range.

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Correct Answer is B

Explanation

Choice A rationale: A normal capillary refill time is less than 3 seconds, which indicates adequate blood flow and oxygenation.

Choice B rationale: Radial pulses 2+ with regular rate and rhythm bilaterally are expected findings in a peripheral vascular assessment, indicating normal blood flow to the extremities.

Choice C rationale: Pale and cool feet may indicate decreased blood flow and are not expected findings.

Choice D rationale: Ankle edema may indicate venous insufficiency or other circulatory issues, and it is not an expected finding in a healthy peripheral vascular assessment.

A. Heart failure B. Excess fluid retention C. Excess fluid consumption D. Pulmonary embolism

Correct Answer is A

Explanation

Choice A rationale: Severe bilateral lower extremity edema is commonly associated with heart failure. In heart failure, the heart's ability to pump blood is compromised, leading to fluid retention and peripheral edema.

Choice B rationale: Excess fluid retention is more of a symptom rather than an underlying cause. Heart failure is a condition that can lead to fluid retention.

Choice C rationale: Excess fluid consumption is unlikely to be the primary cause of severe bilateral lower extremity edema. Underlying medical conditions, such as heart failure, are more likely.

Choice D rationale: While a pulmonary embolism can lead to cardiovascular compromise, severe bilateral lower extremity edema is more commonly associated with heart failure.

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The nurse is percussing a client’s abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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