Procedures - NCLEX-PN

When percussing the seventh intercostal space along the right midclavicular line, you should expect to hear a dull note, as this is directly over the solid mass of the liver.

The border of the liver can be found by percussing in a descending line along the intercostal spaces of the right midclavicular line, starting at the clavicle. The superior border of the liver can be measured at the point where percussion transforms from resonant or hyperresonant (indicating the air-filled lung) to dull (indicating the solid mass of the liver).

A healthy and normal abdominal aorta will measure between 2.5-3cm in diameter. An abdominal aorta over 3cm and under 5cm in diameter is considered to be enlarged, and surgery to prevent abdominal aortic aneurism is generally performed on abdominal aortas that surpass 5cm in diameter in females or 5.5cm in diameter in males.

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.

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.

Washed red blood cells are the product of blood that has been stripped of plasma, leukocytes, antibodies, cytokines, and platelets, in addition to any other blood proteins.

Washed red blood cells are generally prepared for patients with a history of severe allergic reaction to blood transfusion. Washed red blood cells are not generally required in patients with kidney disease, patient who are immunocompromised, or patients with metastatic disease.

Before administration, plasma products must be checked for ABO compatibility and Rh compatibility.

ABO blood type does not have to be an exact match, but blood types must be compatible. An Rh positive individual, for example, is compatible with either Rh negative blood or positive blood, while an Rh negative individual is only compatible with Rh negative blood.

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

Normal levels for sodium are between . Anything below (hyponatremia) or above (hypernatremia) this is considered abnormal and should be evaluated further.

The range for normal potassium levels in blood is . Anything above that (hyperkalemia) or below that range (hypokalemia) is considered abnormal.

The normal adult reference range for blood calcium levels is .

An adult male hematocrit is considered normal when between . Anything below this may indicate anemia, elevated white blood cell count, or blood loss, while numbers above this may indicate dehydration, chronic oxygen deficiency, or a condition of excess red blood cell production (such as polycythemia vera).

Whenever possible, fresh frozen plasma should be transfused immediately (or as soon as possible) after thawing. However, if this is not possible, it may be refrigerated for as long as 24 hours after thawing.

Common signs of transfusion reaction include urticaria, itching, or swelling, pallor or cyanosis, anxiety, and myalgia, tingling, or numbness, in addition to diaphoresis, tachycardia, headache, and gastrointestinal distress.

Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm.

Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.

When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.

The normal reference range for an adult female hematocrit is . Anything below this may indicate anemia, elevated white blood cell count, or blood loss, while numbers above this may indicate dehydration, chronic oxygen deficiency, or a condition of excess red blood cell production (such as polycythemia vera).

A normal erythrocyte sedimentation rate should be below . Anything above this indicates some sort of inflammatory process.