When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time?

Question

Quizplus · Accepted Answer

Percussing the upper border of the liver is the correct technique to use when an enlarged liver is found (as indicated by the liver being percussed 5 cm below the costal margin) to determine the liver span. Documenting this as a normal finding for an adult patient is incorrect because this finding indicates an enlarged liver. Palpating the gallbladder for tenderness is not indicated for an enlarged liver. Using the hooking technique to palpate the lower border of the liver is not needed because the liver is enlarged.

When Assessing an Adult's Liver, the Nurse Percusses the Lower