In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Determine the client's most recent hemoglobin level.

Document the presence of nailbed clubbing.

Administer a PRN prescription for oxygen.

Consult with a podiatrist to trim the client's toenails.

Answer and Explanation

The Correct Answer is B

A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

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Correct Answer is B

Explanation

A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.

B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.

C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.

D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?

Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

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In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Which method is best for the nurse to use in determining early development of ascites?

Correct Answer is B

Explanation

The school nurse is interviewing an adolescent who wants to go home from school because of "back pain." Which question should the nurse ask first?

Correct Answer is A

Explanation

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