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A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)
- A. Palpate the area behind the ankle bone.
- B. Use the pads of the fingers to feel for the pulse.
- C. Compare the pulse strength with the other leg.
- D. Assess for any swelling or tenderness.
Correct Answer: A,B,C
Rationale: The correct actions to assess the posterior tibial pulse are A, B, and C. A: Palpating the area behind the ankle bone locates the posterior tibial pulse accurately. B: Using the pads of the fingers helps to detect the pulse's strength and regularity. C: Comparing pulse strength with the other leg enables the nurse to identify any discrepancies. D: Assessing for swelling or tenderness is not directly related to locating the pulse. Therefore, choices D, E, F, and G are incorrect for assessing the posterior tibial pulse.
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A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?
- A. To limit the amount of bleeding and clots from the surgical site.
- B. To eliminate the need for wound irrigations.
- C. To prevent drainage from accumulating in the wound.
- D. To provide a means for medication administration.
Correct Answer: C
Rationale: Rationale:
The correct answer is C: To prevent drainage from accumulating in the wound. A Jackson-Pratt drain is used to remove excess fluids (such as blood or serous fluid) from a surgical site to prevent accumulation, which can lead to infection or delayed healing. The drain creates negative pressure, allowing drainage to be collected in a bulb or reservoir outside the body. This promotes wound healing by preventing the buildup of fluid.
Incorrect choices:
A: To limit bleeding - While a JP drain may indirectly help limit bleeding by removing excess fluid, its primary purpose is to prevent fluid accumulation.
B: To eliminate wound irrigations - JP drains do not eliminate the need for wound irrigations; they are used for drainage removal.
D: Medication administration - JP drains do not provide a means for medication administration; they are specifically for drainage removal.
A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
- A. I will lie on my left side to sleep at night.
- B. I will lie on my right side to sleep at night.
- C. I will sleep on my back with my head flat.
- D. I will sleep on my stomach with my head flat.
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the anatomical positioning of the stomach and esophagus. When lying on the left side, the stomach is positioned below the esophagus, reducing the likelihood of reflux.
Incorrect choices:
B: Lying on the right side can worsen reflux symptoms as it allows stomach acid to flow back into the esophagus more easily.
C: Sleeping on the back with the head flat may not be as effective in preventing reflux compared to the left side position.
D: Sleeping on the stomach with the head flat can exacerbate reflux symptoms by putting pressure on the stomach and pushing acid back up into the esophagus.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid handwashing after eating.
- B. Avoid foods prepared with tap water.
- C. Avoid eating meat.
- D. Avoid covering sores with bandages.
Correct Answer: B
Rationale: The correct answer is B: Avoid foods prepared with tap water. This is important because tap water in certain regions may be contaminated with hepatitis-causing viruses. Avoiding tap water in food preparation reduces the risk of contracting viral hepatitis. Handwashing after eating (A) is actually recommended for preventing the spread of infections. Avoiding eating meat (C) is not necessary for preventing viral hepatitis transmission. Covering sores with bandages (D) is unrelated to the prevention of viral hepatitis.
A nurse is caring for an 84-year-old male client in the medical unit. The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
- A. Teach the client about the condition.
- B. Encourage intake of low-sodium diet.
- C. Administer prescribed medications.
- D. Monitor vital signs regularly.
- E. Schedule a follow-up appointment with a specialist.
- F. Anemia
- G. Blood pressure
Correct Answer: A,C,D,E
Rationale: The correct answer is A,C,D,E. Firstly, the client is likely experiencing anemia based on the symptoms of fatigue, dizziness, and shortness of breath. Therefore, administering prescribed medications (C) to address the anemia is crucial. Teaching the client about the condition (A) helps improve understanding and compliance. Monitoring vital signs (D) is essential to track the client's response to treatment. Scheduling a follow-up appointment with a specialist (E) ensures ongoing evaluation and management. Encouraging intake of a low-sodium diet (B) is not directly related to anemia and may not be the priority in this case. Blood pressure (G) monitoring is important but not specific to anemia.
The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
- A. Red skin with edema in the nail beds.
- B. Black fingertips surrounded by an erythematous rash.
- C. A white appearance to the skin that is insensitive to touch.
- D. A pink edematous hand.
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (Choice A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (Choice B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (Choice D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.