The client is brought into the emergency room (ER) by paramedics with blunt trauma to the left upper side of the abdomen due to a motor vehicle accident. The ER nurse knows what organ is most likely impacted.
appendix
left ureter
left lobe of liver
sigmoid colon
The Correct Answer is C
A. Appendix: Located in the right lower quadrant, the appendix is unlikely to be impacted in left upper quadrant trauma.
B. Left ureter: The left ureter is located lower in the abdomen along the flank area and is not directly impacted in the left upper quadrant.
C. Left lobe of liver: The liver’s left lobe extends into the left upper quadrant, making it a likely organ to be impacted in blunt trauma to this area, particularly given its large size and location near the abdominal wall.
D. Sigmoid colon: Positioned lower in the left lower quadrant, the sigmoid colon is less likely to be affected by left upper abdominal trauma.
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Correct Answer is D
Explanation
A. A client who has pneumonia: Pneumonia typically requires droplet precautions, not airborne.
B. A client who has shigella: Shigella is transmitted through the fecal-oral route, so contact precautions would be appropriate.
C. A client who has strep throat: Streptococcal infections are spread by droplets, so droplet precautions are indicated, not airborne.
D. A client who has tuberculosis: Tuberculosis (TB) is spread via airborne droplets, so airborne precautions are necessary to prevent transmission.
Correct Answer is A
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.