Difficulty: Medium
Average Score: 67%
Simulated
The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Recognizes this dullness as indicative of an enlarged liver and refers the client to a provider. This answer is correct because dullness above the right costal margin can indicate hepatomegaly (enlarged liver), which may be due to various conditions like liver disease or infection. Referring the client to a healthcare provider is essential for further evaluation and appropriate management.
Choice B is incorrect because simply documenting the presence of hepatomegaly without further action could delay necessary medical intervention. Choice C is incorrect as asking about alcohol intake alone may not provide a comprehensive assessment of the client's condition. Choice D is incorrect because dullness above the right costal margin is not a normal finding and should not be overlooked.
Choice B is incorrect because simply documenting the presence of hepatomegaly without further action could delay necessary medical intervention. Choice C is incorrect as asking about alcohol intake alone may not provide a comprehensive assessment of the client's condition. Choice D is incorrect because dullness above the right costal margin is not a normal finding and should not be overlooked.