health assessment exam 2 test bank

Correct Answer: B

Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.

Correct Answer: C

Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.

Correct Answer: B

Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.

Correct Answer: B

Rationale: The correct answer is B because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.