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During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client's pulse deficit (per minute)?
- A. 16
- B. 12
- C. 6
- D. 14
Correct Answer: A
Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.
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The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?
- A. Tops of the ears
- B. Bridge of the nose
- C. Around the nostrils
- D. Over the cheeks
Correct Answer: A
Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.
A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?
- A. "I am afraid to walk if it hurts too much."
- B. "I don't understand why I need this surgery."
- C. "I don't want my family helping me after the surgery."
- D. "I am afraid the scar will make me look disfigured."
Correct Answer: B
Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.
A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?
- A. Place the bladder of the cuff over the posterior aspect of the thigh
- B. Use a smaller cuff designed for lower extremities
- C. Place the cuff around the client's ankle
- D. Ensure the cuff is positioned above the knee
Correct Answer: A
Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.
A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
- A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
- B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
- C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
- D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.
Correct Answer: C
Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.
A healthcare professional is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the healthcare professional use first?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: Inspection is the initial step in abdominal assessment as it allows the healthcare professional to visually observe any abnormalities or signs of bloating. Palpation, auscultation, and percussion are subsequent assessment techniques that follow inspection. Palpation involves feeling for tenderness, masses, or organ enlargement; auscultation is listening for bowel sounds; and percussion is used to assess the density of underlying tissues or detect the presence of fluid or air in the abdomen. In the context of a client reporting bloating, the first step should be visual inspection to gather initial information. Palpation, auscultation, and percussion come after inspection to provide a more comprehensive assessment.