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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Finding a firm, irregularly shaped mass during a rectal examination raises concerns about the possibility of colorectal pathology, including cancer. The nurse should report the finding and refer the client to a specialist for further examination and diagnostic testing.
Choice B rationale: Dismissing the mass without further investigation may lead to a delay in diagnosis and appropriate treatment.
Choice C rationale: Instructing the client to return for a repeat assessment in 1 month is not appropriate when a potentially serious finding is present. Immediate referral for further evaluation is necessary.
Choice D rationale: Continuing the examination without addressing the finding and obtaining appropriate follow-up could compromise the client's health and delay necessary interventions.
Correct Answer is C
Explanation
Choice A rationale: The vas deferens is a duct that carries sperm from the testes to the urethra but is not a glandular structure.
Choice B rationale: The scrotum is a pouch of skin and muscle that houses and protects the testes but is not a glandular structure.
Choice C rationale: The prostate is an accessory glandular structure for the male genital organs. It produces a fluid that combines with sperm and seminal vesicle fluid to form semen.
Choice D rationale: The testis is a male reproductive organ that produces sperm and testosterone but is not an accessory glandular structure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today