Nokea
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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The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
- A. The client with asthma who is now ready for discharge
- B. The client with a peptic ulcer who has been vomiting all night
- C. The client with chronic renal failure returning from dialysis
- D. The client with pancreatitis who was admitted yesterday
Correct Answer: B
Rationale: The client with a peptic ulcer who has been vomiting all night. Persistent vomiting can lead to dehydration, electrolyte imbalances, and potential complications such as perforation or bleeding in a client with a peptic ulcer, requiring immediate assessment.
A client with a partial bowel obstruction has a Miller-Abbot tube inserted to decompress the bowel. While the tube is in place, the nurse should give priority to:
- A. Using only normal saline to irrigate the tube every 4 hours
- B. Advancing the tube 3-4 inches as ordered by the physician
- C. Changing the tape securing the tube to the client's face daily to prevent skin breakdown
- D. Attaching the tube to high constant suction
Correct Answer: C
Rationale: Preventing skin breakdown by changing the tape daily is critical to avoid tissue damage around the insertion site. Irrigation and suction settings depend on physician orders, and advancing the tube is not a nursing priority without specific instructions.
During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?
- A. Check the child for parasitic infections
- B. Consult a pediatric nutritionist for suspected eating disorder
- C. Notify the health care provider
- D. Reinforce teaching about the toddler's nutritional needs
Correct Answer: D
Rationale: Toddlers often eat small amounts due to slower growth rates and picky eating. Educating parents about normal toddler nutrition addresses concerns and promotes appropriate feeding practices.
Spirituality affects a client's life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct Answer: D
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy and does not have any effect on genetic makeup.
A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
- A. Give acetaminophen or ibuprofen every 6-8 hours to control fever.
- B. Give the infant frequent tepid sponge baths to control the fever.
- C. If the infant develops another seizure, wait 15 minutes to see if it subsides.
- D. Place ice bags under the arms and around the neck to control fever.
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.