Procedures

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NCLEX-PN › Procedures

Questions 1 - 10
1

A patient reports to urgent care for colicky pain in the upper right quadrant that they rate as a seven out of ten. The night before they ate a fatty meal with two glasses of wine. Which of the following tests would help you asses for cholecystitis?

Murphy's sign

Mc Burney's point

Psoas sign

Rovsing's sign

Explanation

A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.

Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.

2

A patient reports to urgent care for colicky pain in the upper right quadrant that they rate as a seven out of ten. The night before they ate a fatty meal with two glasses of wine. Which of the following tests would help you asses for cholecystitis?

Murphy's sign

Mc Burney's point

Psoas sign

Rovsing's sign

Explanation

A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.

Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.

3

A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?

3% increase

15% increase

5% decrease

20% increase

Explanation

A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.

4

A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?

3% increase

15% increase

5% decrease

20% increase

Explanation

A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.

5

When testing for the strength of the left biceps brachii muscle, a patient is found to be able to move freely against gravity, but is unable to flex against very gentle resistance by the examiner. What grade of muscle strength should their bicep be assigned?

Explanation

In this case, the patient is able to move their biceps brachii against gravity, but they are unable to move against gentle resistance by the examiner. This means the muscle strength should be graded at .

The muscle strength grade is as follows:

: no contraction

: muscle contraction, but no movement

: movement with gravity, but not against gravity

: movement against gravity, but not against resistance

: movement against mild resistance by the examiner

: normal muscle strength

6

A stethoscope has two components to the chest piece. These are called the __________ and the __________.

bell . . . diaphragm

cone . . . disc

bell . . . disc

cone . . . diaphragm

Explanation

The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.

7

When testing for the strength of the left biceps brachii muscle, a patient is found to be able to move freely against gravity, but is unable to flex against very gentle resistance by the examiner. What grade of muscle strength should their bicep be assigned?

Explanation

In this case, the patient is able to move their biceps brachii against gravity, but they are unable to move against gentle resistance by the examiner. This means the muscle strength should be graded at .

The muscle strength grade is as follows:

: no contraction

: muscle contraction, but no movement

: movement with gravity, but not against gravity

: movement against gravity, but not against resistance

: movement against mild resistance by the examiner

: normal muscle strength

8

A stethoscope has two components to the chest piece. These are called the __________ and the __________.

bell . . . diaphragm

cone . . . disc

bell . . . disc

cone . . . diaphragm

Explanation

The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.

9

Which of the following would be considered a normal adult blood pressure?

110/72 mmHg

124/84 mmHg

88/56 mmHg

132/88 mmHg

Explanation

Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.

10

Which of the following is not determined by urinalysis?

All of these are determined by urinalysis

pH

Specific gravity

Presence of blood

Presence of bacteria

Explanation

A urinalysis can be an important tool in diagnosis conditions such as the presence of kidney stones, urinary tract infection and even dehydration. A typical urinalysis will contain information on all of the parameters indicated. The presence of glucose, ketones, crystals, casts, and leukocyte esterase may also be included.

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