Nokea
A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?
- A. Capillaries
- B. Pedal pulses
- C. Femoral arteries
- D. Radial and ulnar arteries
Correct Answer: D
Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.
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Which of the following is least appropriate when caring for a stable postpartum client?
- A. Assess the location and height of the fundus.
- B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
- C. Monitor the client for bleeding.
- D. Provide perineal care.
Correct Answer: D
Rationale: Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.
A nurse assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?
- A. The client has a fever.
- B. The skin temperature is normal.
- C. The client needs to drink additional fluids.
- D. The client needs to have the blanket removed.
Correct Answer: B
Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.
An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?
- A. The client has a low cardiac output.
- B. The client has a high cardiac output.
- C. The client has a normal cardiac output.
- D. The client will need a blood transfusion.
Correct Answer: C
Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.
A 37-year-old female client asks the nurse about contraception options and expresses interest in oral contraception pills. Which of the following statements would indicate that oral contraception is appropriate for this client?
- A. "I quit smoking last year, but I started again recently. Maybe I'll try to quit later this year."?
- B. "I am very diligent in taking my thyroid medications at the same time every day."?
- C. "I was hospitalized for deep vein thrombosis five years ago."?
- D. "I was recently diagnosed with breast cancer."?
Correct Answer: C
Rationale: The correct answer is the statement mentioning a history of deep vein thrombosis five years ago. Oral contraceptives are generally not recommended for individuals with a history of deep vein thrombosis due to the increased risk of blood clots. Choice B, about being diligent in taking thyroid medications, does not directly relate to the safety of using oral contraceptives. Choice D, about a recent breast cancer diagnosis, would contraindicate the use of hormonal contraceptives. Choice A, mentioning a recent return to smoking, raises concerns about using hormonal contraceptives due to the increased risk of cardiovascular complications.
During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?
- A. Documents the normal finding
- B. Checks for penile discharge, as this indicates infection
- C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
- D. Obtains additional subjective data from the client, focusing on the scrotal abnormality
Correct Answer: A
Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.