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A nurse and AP are caring for a patient who just returned from the operating room after a femoral-popliteal arterial bypass graft. The nurse is getting another admission. What activity can the nurse safely delegate to the AP?
- A. Determining if pedal pulses are present
- B. Evaluating the patient's pain
- C. Reinforcing the sterile dressing
- D. Ordering dressing supplies
Correct Answer: D
Rationale: The nurse can delegate noncomplex activities to the AP such as obtaining (dressing) supplies, bedmaking, bathing, I & O, toileting, and ambulation. The nurse must perform assessments, provide teaching, perform sterile procedures, and develop the care plan.
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A nurse on a medical-surgical unit is caring for a group of patients. For which patient will the nurse perform a focused assessment?
- A. Newly admitted
- B. Recent application of a wrist cast
- C. Signs of acute respiratory distress
- D. Post-abdominal surgery without complications
Correct Answer: B
Rationale: After application of a cast, the nurse performs a focused neurovascular assessment, to assess circulation, sensation, and motor ability. A newly admitted patient requires a comprehensive assessment. The nurse performs an emergency assessment on a patient who presents with signs of acute respiratory difficulty. A postoperative patient without complications will receive ongoing assessments at regular intervals to evaluate the effectiveness of care and to assess for new problems.
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes the skin has a yellow tint. What term will the nurse use to document the skin assessment in the electronic health record?
- A. Jaundice
- B. Cyanosis
- C. Erythema
- D. Pallor
Correct Answer: A
Rationale: Jaundice refers to a yellowish skin color caused by liver, gallbladder, or pancreatic diseases. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.
The nurse is caring for a patient experiencing bronchospasm due to an exacerbation of asthma. During auscultation, the nurse anticipates the presence of which breath sound?
- A. Sibilant
- B. Wheezes
- C. Rhonchi
- D. Crackles
Correct Answer: B
Rationale: Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways, such as with bronchospasm found in asthma or COPD. Rhonchi are low-pitched, continuous sounds with a snoring quality, which may clear with coughing; they occur when air passes through secretions. Crackles are discontinuous bubbling, cracking, or popping, low- to high-pitched sounds, that occur when air passes through fluid in the airways.
A nursing student is learning to perform physical assessments. When will the student use the technique of palpation? Select all that apply.
- A. Assessing temperature of a patient's feet
- B. Counting the apical pulse
- C. Assessing for skin turgor
- D. Evaluating lymph nodes
- E. Assessing for dullness over a tumor
- F. Finding a heart murmur
Correct Answer: A,C,D
Rationale: During palpation, the nurse uses the sense of touch to compare bilateral pulses for symmetrical temperature, assess skin turgor, and check for enlarged lymph nodes. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds provide information about the location, shape, size, and density of tissues, such as dullness over a mass or fluid accumulation. Auscultation refers to listening with a stethoscope to sounds produced in the body; counting the apical pulse or auscultating heart sounds/murmurs are examples.
A nurse is caring for a patient with exacerbation of COPD and pneumonia. When auscultating the lungs, coarse expiratory, low-pitched, and continuous sounds that clear with coughing are present. How will the nurse document this breath sound in the electronic health record?
- A. Rhonchi
- B. Bronchovesicular breath sounds
- C. Stridor
- D. Bronchial breath sounds
Correct Answer: A
Rationale: Rhonchi are abnormal low-pitched, continuous breath sounds auscultated during inspiration and occasionally expiration, indicating that air is passing through or around secretions. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Stridor is a harsh, loud, high-pitched sound auscultated on inspiration indicating narrowing of the upper airway or presence of a foreign body. Bronchial sounds are normal blowing, hollow sounds, auscultated over the larynx and trachea.