Nokea
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?
- A. Auscultate the pulses with a stethoscope
- B. Call the physician
- C. Use a Doppler ultrasound device
- D. Inspect the lower left extremity
Correct Answer: C
Rationale: If pedal pulses are not palpable, the next step is to use a Doppler ultrasound device to detect blood flow, as pulses may be weak due to PVD or other causes. Auscultation is not used for peripheral pulses, calling the physician is premature, and inspection is less specific than Doppler assessment.
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Which outcome is appropriate for a client with a traumatic brain injury?
- A. Complete memory recovery.
- B. Active participation in therapy.
- C. Return to pre-injury job.
- D. Eliminate all symptoms.
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
- A. Encourage the client to apply full weightbearing.
- B. Order a walker for the client.
- C. Place a straight-backed chair at the foot of the bed.
- D. Apply a knee immobilizer.
Correct Answer: D
Rationale: A knee immobilizer ensures stability and safety during initial transfers post-surgery.
The nurse is assisting a client with crutches to ascend stairs. Which instruction is correct?
- A. Step up with the affected leg first.
- B. Use the handrail on the unaffected side.
- C. Advance both crutches to the next step first.
- D. Lean backward while stepping up.
Correct Answer: B
Rationale: Using the handrail on the unaffected side provides stability and safety while ascending stairs.
When caring for a client with a chest tube and water-seal drainage system, the nurse should:
- A. Verify that the air vent on the water-seal drainage system is capped when the suction is off.
- B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs.
- C. Ensure that the chest tube is clamped when moving the client out of the bed.
- D. Make sure that the drainage apparatus is always below the client's chest level.
Correct Answer: D
Rationale: Keeping the drainage apparatus below chest level prevents fluid backflow into the pleural space. Capping the vent, stripping tubes, or clamping during movement risks complications like pneumothorax.