Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient had abdominal surgery yesterday when auscultating his abdomen, you would expect to hear:
A. High-pitched, tinkling sounds
High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sound
Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds
Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds
Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.
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Full Explanation
A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.
Similar Questions
The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate?
A. "If you notice an enlarged testicle or a painless lump, call your health care provider."
This emphasizes recognizing abnormal findings, such as an enlarged testicle or a painless lump, which may indicate testicular cancer.
B. "The testicle is egg shaped and movable. It feels firm and has a lumpy consistency."
Testicles are smooth, firm, and egg-shaped but should not have a lumpy consistency.
C. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer."
Monthly, not weekly, self-examinations are recommended for early detection.
D. "A good time to examine your testicles is just before you take a shower."
The best time to examine is during or after a warm shower when the scrotum is relaxed, not before.
Full Explanation
A. This emphasizes recognizing abnormal findings, such as an enlarged testicle or a painless lump, which may indicate testicular cancer.
B. Testicles are smooth, firm, and egg-shaped but should not have a lumpy consistency.
C. Monthly, not weekly, self-examinations are recommended for early detection.
D. The best time to examine is during or after a warm shower when the scrotum is relaxed, not before.
A nurse performs the Weber test on a healthy adult client. The nurse would expect which of the following normal finding?
A. Air conduction greater than bone conduction.
Air conduction greater than bone conduction: This is tested with the Rinne test, not the Weber test.
B. Bilateral hearing loss.
Bilateral hearing loss: This is not a normal finding in the Weber test.
C. No lateralization of vibrations.
No lateralization of vibrations: In a normal Weber test, the vibrations are heard equally in both ears, indicating no conductive or sensorineural hearing loss.
D. unilateral hearing loss.
Unilateral hearing loss: This would be abnormal and suggest hearing impairment in one ear.
Full Explanation
A. Air conduction greater than bone conduction: This is tested with the Rinne test, not the Weber test.
B. Bilateral hearing loss: This is not a normal finding in the Weber test.
C. No lateralization of vibrations: In a normal Weber test, the vibrations are heard equally in both ears, indicating no conductive or sensorineural hearing loss.
D. Unilateral hearing loss: This would be abnormal and suggest hearing impairment in one ear.
The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?
A. Consider this a normal capillary refill time that requires no further assessment.
Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. Consider this a delayed capillary refill time, and investigate further.
A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. Ask the patient about a history of frostbite.
While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Suspect that the patient has venous insufficiency.
Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
Full Explanation
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.