To palpate the liver during a head-to-toe physical assessment, ...

[mmm]

To palpate the liver during a head-to-toe physical assessment, the nurse
 
  a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin.
  b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge.
  c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt.
  d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

Question 2

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit?
 
  a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome.
  b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis.
  c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy.
  d. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

[babybsemail]

Answer to Question 1

ANS: A
The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.

Answer to Question 2

ANS: D
Under the supervision of registered nurses (RNs), UAP check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

[mmm]

Correct answers!

[babybsemail]

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