When assessing the lymph nodes, the nurse should: (select all that apply)
Assess unilaterally.
Assess mobility.
Assess the size and shape.
Assess bilaterally.
Correct Answer : B,C,D
Assessing unilaterally is not recommended as it may lead to missing important findings on one side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Assessing unilaterally is not recommended as it may lead to missing important findings on one side.
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.
Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
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