Nokea
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
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A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
- A. Provide support by holding the client's arm.
- B. Lean the client toward the wall.
- C. Lower the client to the floor.
- D. Maintain a narrow base of support.
Correct Answer: C
Rationale: The correct action for the nurse to take when a client begins to fall during ambulation is to lower the client to the floor (Choice C). This is the safest option to prevent further injury to the client. Lowering the client to the floor helps minimize the distance of the fall, reducing the risk of serious injury. Additionally, it allows for a controlled descent, ensuring the client lands safely. Providing support by holding the client's arm (Choice A) may not be enough to prevent a fall and could lead to both the nurse and the client getting injured. Leaning the client toward the wall (Choice B) may not provide adequate support and could still result in a fall. Maintaining a narrow base of support (Choice D) may not be effective in preventing a fall. The best course of action is to prioritize the safety of the client by lowering them to the floor in a controlled manner.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.