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To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Palpate the site on the inner side of the ankle below the medial malleolus.
- C. Obtain a doppler stethoscope to auscultate the pulse at the same site.
- D. Document in the nurses' notes that the dorsalis pedis pulse is not palpable.
Correct Answer: A
Rationale: Reducing pressure may reveal the pulse.
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Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
- A. The technique is intended to maintain straight spinal alignment.
- B. Working together can decrease the risk of back injury to the nurses.
- C. Using two or three people increases client safety.
- D. Turning instead of pulling reduces the likelihood of skin damage.
Correct Answer: A
Rationale: Log rolling maintains spinal alignment for safety.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Tennis shoes with velcro.
- B. Rubber-soled slippers.
- C. Slip-on rubber shower shoes.
- D. Leather-soled loafers.
Correct Answer: A
Rationale: Velcro tennis shoes provide support and stability.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Instruct the client to use guided imagery and slow rhythmic breathing.
- B. Place a hot water circulation device, such as an Aqua K pad, to the operative site.
- C. Tune to a television show or easy listening music to provide distraction.
- D. Provide at least 20 minutes of back massage and gentle effleurage.
Correct Answer: A
Rationale: Guided imagery promotes relaxation to manage moderate pain.
The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
- A. Warn the colleague that their actions are unprofessional.
- B. Discuss the action at the next staff meeting.
- C. Communicate the observation to the charge nurse.
- D. File a detailed incident report with the specific facility.
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.
The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
- A. Morphine 2.0 mg IV every four hours for severe pain.
- B. Morphine 2 mg IV every 4 hr PRN for severe pain.
- C. IV MS 2 mg every 4 hr as needed for severe pain.
- D. IV MS 2.0 mg every 4 hours PRN for severe pain.
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.