Nokea
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.
You may also like to solve these questions
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- A. I will have blood drawn every month.'
- B. I will assess my skin for a rash.'
- C. I take aspirin for a headache.'
- D. I will use an electric razor to shave.'
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.
Home-care instructions for the child following a cardiac catheterization should include:
- A. Notify the physician if a slight bruise develops around the insertion site.
- B. Use sponge bathing until stitches are removed.
- C. Give aspirin if the child complains of pain at the insertion site.
- D. Keep a clean, dry dressing on the insertion site for 2 days.
Correct Answer: B
Rationale: A small bruise may develop around the insertion site and is not a reason for alarm. It is best to keep the child out of the bathtub until the sutures are removed. Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. The insertion site should be kept clean and dry and open to air.
The nurse is caring for a client with a history of a seizure disorder who is receiving Carbamazepine (Tegretol). The nurse should monitor the client for:
- A. Leukopenia
- B. Hypotension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Carbamazepine can cause leukopenia, requiring monitoring of white blood cell counts. Hypotension, hyperglycemia, and weight gain are not primary side effects.
While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor.
- B. Avoid sun exposure while using the herbal supplement.
- C. Purchase only those brands with FDA approval.
- D. Increase daily intake of vitamin E.
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by inhibiting platelet aggregation, so clients should report signs of bruising or bleeding to their doctor.
The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?
- A. Hematocrit
- B. Serum creatinine
- C. White cell count
- D. BUN
Correct Answer: B
Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.