A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?
Document information directly from a textbook.
Copy previous nursing assessment.
Document their findings.
Seek clarification from a more experienced nurse.
The Correct Answer is D
A. Documenting information directly from a textbook is incorrect because textbooks provide general guidelines, not client-specific data. The student's assessment findings should be based on the actual client’s condition.
B. Copying a previous nursing assessment is incorrect and unethical. Each assessment must be conducted independently to ensure accurate and up-to-date client care.
C. Documenting findings without confidence in their accuracy can lead to errors in client care. If the student is uncertain, verification is necessary before documentation.
D. Seeking clarification from a more experienced nurse is correct. If a student nurse is unsure of their assessment findings, they should ask a preceptor or experienced nurse for guidance to ensure accuracy and safe client care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.
Correct Answer is B
Explanation
A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.
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