Question 4 type mcsa the nurse evaluates which

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Question 4 Type: MCSA The nurse evaluates which patient observation as indicating the patient correctly understands the functions of the stomach? 1. “The process of absorption of nutrients begins in my stomach.” 2. “My stomach turns food into liquid so it can be digested.” 3. “My stomach begins the digestion of carbohydrates.” 4. “Sulfuric acid is secreted by the stomach.” Correct Answer: 2
Rationale 1 : The process of absorption begins in the small intestine. Rationale 2 : In the stomach, food continues to be turned to liquid so that it may ultimately be absorbed into the bloodstream. Rationale 3 : Carbohydrate digestion begins in the mouth. Rationale 4 : The stomach secretes hydrochloride, not sulfuric acid. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-1 Question 5 Type: MCSA A nurse preceptor is reviewing the skill of percussing a patient’s abdomen with a newly licensed nurse. The preceptor will intervene when the nurse makes which statement?
2. “I anticipate hearing tympany over stool-filled intestines.” 3. “Dullness is the expected percussion over the liver.” 4. “Percussion is a useful tool for assessing the spleen, kidneys, and liver.” Correct Answer: 2 Rationale 1 : The nurse should establish a system of assessment. Rationale 2 : Tympany is heard over air-filled organs such as gas-filled intestines. Intestines that are stool-filled, such as in a patient with an ileus or constipation, present dull sounds. Rationale 3 : The liver gives off a dull sound. Rationale 4 : The nurse would percuss over the spleen, kidneys, and liver. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36-3 Question 6 Type: MCSA When assessing a patient who is scheduled to have a CT scan of the kidneys, which finding would prompt the nurse to notify the primary health care provider? 1
Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36-5

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