Set 6

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtaining medical history C. Measure vital signs D.Assess for leg pain

A.Evaluate pedal pulses For a client who has decreased circulation in the way, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority setting framework. This framework for science party to the factor posing the greatest safety risk to the client. When there are several risk to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, and/or nursing knowledge to identify which risk produces the greatest threat to the client.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the clients body? A. Heart B. Lungs C. Thyroid gland D.Skin

B. Lungs Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as residence (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs

A nurse in a providers office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicates an understanding of the teaching? Select all that apply A. Canned peaches B. White rice C. Black beans D. Whole grain bread E.Tomato juice

C. Black beans D. Whole grain bread Dried peas and beans, including black beans, or high in fiber whole greens consist of the entire kernel that are also high in fiber.

A nurse is preparing to assess the function of the claims trigeminal nerve (cranial nerve five). Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D.Snellen chart

C.Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve five, the nurse should ask the client to client to the teeth

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? Select all that apply A. Sit with your back supported B. Keep your knees at hip level C. Use an ergonomically designed computer keyboard D. Keep your elbows away from your body E.I just the monitor screen so that you have to tilt your head slightly to look at it

A. Sit with your back supported B. Keep your knees at hip level C.Use an economically designed computer keyboard Using lumbar support in a straight back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher how to reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains an ergonomic position of the wrist can help prevent carpal tunnel syndrome.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following client should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. Client who has emphysema and is receiving oxygen at 3 L per minute via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D.A client who has COPD and is receiving oxygen at 2 L per minute via nasal cannula

A. The client who has heart failure and is receiving 100% oxygen via partial rebreather mask The nurse should apply the safety and risk reduction priority setting framework, which is signs party to the factor or situation posing the greatest safety risk to the client. When there are several risk to client safety, the one putting the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhale carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas but I can cause toxicity and is highly combustible, and higher concentration of oxygen increase the risk of client injury

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique clarifying? A. Now that we have talked about your medications, let's talk about your pain. B. Are you having other symptoms? C. It sounds like your pain is intermittent D. It seems as though you have really had a rough time these past few weeks

C. It sounds like your pain is intermittent This response by the nurse reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the clients message.

A nurse is assessing a clients peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60 bpm B. Radio, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetrical, equal, and strong in all four extremities D.Brachial, radio, popliteal, and dorsalis pedis pulse is regular, 58, and bilaterally palpable

C. Peripheral pulses bilaterally symmetrical, equal, and strong in all four extremities The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulseEvaluation is full for specific clinical indications such as circulatory impairment and extremity ordering a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpitation of the radio, radio, owner, from all, Papa teal, cereal, and dorsalis pedis pulses. Documentation of peripheral pulses evaluation should include the strength of position as well as their equality and symmetry in all four extremities.