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To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)
- A. Posterior tibial artery
- B. Radial artery
- C. External iliac artery
- D. Dorsalis pedis artery
Correct Answer: D
Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.
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The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?
- A. Keep the client in a low Fowler's position
- B. Maintain hip abduction with pillows
- C. Encourage early ambulation
- D. Place the client in a prone position
Correct Answer: B
Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.
A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)
- A. Raisin bran muffins
- B. Bowl of oatmeal
- C. Cup of raspberries
- D. Scrambled eggs
Correct Answer: A
Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.
A client reports pain after medication administration. What is the next best step for the nurse?
- A. Reassess the client's pain
- B. Increase the pain medication dose
- C. Apply a cold compress
- D. Contact the healthcare provider
Correct Answer: A
Rationale: The correct answer is to reassess the client's pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.
The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow the rate of transfusion.
- B. Administer an antipyretic.
- C. Stop the transfusion immediately.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.
A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a Lumbar Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?
- A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain
- B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
- C. An infusion of medication in the spinal canal will block pain perception
- D. The discharge of electricity will distract the client's focus on the pain
Correct Answer: A
Rationale: The correct answer is A. TENS units work by delivering small electrical impulses through the skin. These impulses are thought to close the 'gates of nerve conduction,' which can help in managing severe pain. Choice B is incorrect because the dulled pain perception does not occur in the cerebral cortex by the TENS unit. Choice C is incorrect as it describes a different method of pain management involving medication in the spinal canal. Choice D is incorrect because TENS does not work by distracting the client's focus on pain, but rather by altering pain perception through electrical impulses.