The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
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A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?
- A. Faces forward when going up and down the stairs
- B. Holds the cane with the right hand
- C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs
- D. Places full weight on left leg when going down the stairs
Correct Answer: D
Rationale: Placing full weight on the surgical leg when going down stairs risks injury and instability. The client should lead with the cane and unaffected leg, using the surgical leg cautiously.
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?
- A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours
- B. Client with a do-not-resuscitate prescription who has swelling at the IV site
- C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
- D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag
Correct Answer: A
Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.
A client undergoes cryosurgery for the removal of a basal cell carcinoma on the ear. Which of the following best describes the appearance of the area a few days after surgery?
- A. It's dry, crusty, and itchy.
- B. It's oozing and painful.
- C. It's dry and tender.
- D. It's swollen, tender, and blistered.
Correct Answer: A
Rationale: Post-cryosurgery, the treated area typically forms a dry, crusty scab and may be itchy as it heals.
What should be included in the care plan of a client who has myxedema?
- A. Encourage frequent rest periods
- B. Have the client do deep breathing and coughing exercises frequently
- C. Provide a cool environment
- D. Offer frequent high-calorie snacks
Correct Answer: A
Rationale: Myxedema (severe hypothyroidism) causes fatigue; frequent rest periods conserve energy. Deep breathing, cool environments, or high-calorie snacks are not prioritized.