A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

Irregular pulse.

Persistent fatigue.

Dependent edema.

Slurred speech.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Irregular pulse. While an irregular pulse is a common finding in atrial fibrillation, it is not the most critical finding to report immediately unless it is associated with other symptoms.

Choice B rationale

Persistent fatigue. Persistent fatigue is a common symptom in heart failure and atrial fibrillation but does not require immediate reporting unless it worsens significantly.

Choice C rationale

Dependent edema. Dependent edema is a common symptom in heart failure but does not require immediate reporting unless it is severe or worsening rapidly.

Choice D rationale

Slurred speech. This finding is critical to report immediately as it may indicate a stroke or transient ischemic attack (TIA) due to an embolus from atrial fibrillation. Prompt intervention is necessary to prevent further complications. .

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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.

Choice B rationale

A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.

Choice C rationale

Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.

Choice D rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.

Choice E rationale

Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.

A. Palpate the area behind the ankle bone. B. Use the pads of the fingers to feel for the pulse. C. Compare the pulse strength with the other leg. D. Assess for any swelling or tenderness

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.

Choice B rationale

Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.

Choice C rationale

Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.

Choice D rationale

Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.

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A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation.
Which of the following findings should the nurse plan to monitor for and report to the provider immediately?