Exhibits

The client with a cast must have a neurovascular assessment every hour for the first 24 hours and then every 4 to 8 hours after the cast has dried. Assessment of the skin, movement, sensation, pulses, pain and capillary refill are areas of concern.

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Use your thumbnail and press the nailbed proximal to the injury

Pressure placed on the nailbed should cause blanching (pale)

Capillary refill is measured in seconds

Normal should be within 3 seconds or 5 in the older adult

Answer and Explanation

Correct Answer : B,C,D,E

A. Capillary refill is not the time it takes to return to the client's normal color after releasing pressure
B. Use your thumbnail and press the nailbed proximal to the injury: This is the correct technique for assessing capillary refill. You should press on the nailbed until it blanches and then release the pressure.
C. Pressure placed on the nailbed should cause blanching (pale): When pressure is applied to the nailbed, it should turn pale. This is known as blanching.
D. Capillary refill is measured in seconds: The time it takes for the nailbed to return to its normal color is measured in seconds.
E. Normal should be within 3 seconds or 5 in the older adult: A normal capillary refill time is generally considered to be within 3 seconds. However, in older adults, it may take up to 5 seconds for the nailbed to return to its normal color.

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Correct Answer is B

Explanation

A. Flexing the hip and knee while standing may help assess some aspects of hip function but is not as specific for diagnosing hip dysfunction as other procedures.
B. Abducting each hip while the client is supine helps assess hip joint dysfunction by evaluating the range of motion and identifying limitations or pain during movement, which is crucial for diagnosing hip issues.
C. Observing balance while the client stands is more relevant for assessing overall stability and balance rather than specifically diagnosing hip dysfunction.
D. Inspecting gluteal folds for symmetry can provide some information about hip alignment but is less effective in diagnosing specific hip joint dysfunction compared to assessing range of motion or pain during movement.

A. Monitor urinary output B. Obtain an electrocardiogram C. Restrict activity to bed rest D. Initiate NPO status

Correct Answer is D

Explanation

A. Monitoring urinary output is important for assessing kidney function and hydration status, but it is not the immediate priority in this situation. The abrupt cessation of inhalation during palpation suggests acute abdominal pathology that requires immediate attention.
B. Obtaining an electrocardiogram (ECG) is necessary in cases of suspected cardiac issues, but the symptoms described are more indicative of an acute abdominal condition, such as peritonitis or cholecystitis, rather than a cardiac event.
C. Restricting activity to bed rest may help prevent further discomfort or complications, but it is not the most critical immediate action. The client’s acute symptoms suggest the need for more urgent interventions.
D. Initiating NPO (nothing by mouth) status is the most important action because the client may require surgical intervention or further diagnostic testing for an acute abdominal condition. NPO status is essential to prepare the client for potential surgery and to prevent further complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Correct Answer is B

Explanation

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is D

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Which assessment finding supports the client statement, "My feet swell all the time?"

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?