Try Naxlex NCLEX-RN (Free-Trial)

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally.

Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally.

Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical.

Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal.

Answer and Explanation

The Correct Answer is B

A. Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally:
Incorrect. Capillary refill should be less than 2-3 seconds for normal findings; less than 5 seconds would be too long and could indicate poor perfusion. Radial pulses graded +4 are not typical and suggest a bounding pulse, which could indicate an abnormal condition. Grips graded 10/10 is not the standard grading system; typically, grips are graded out of 5.

B. Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally:
Correct. This option uses proper terminology. Capillary refill of less than 3 seconds is normal, radial pulses graded +2 are normal, and grips are appropriately graded on a 5-point scale, with 5/5 being the normal strength.

C. Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical:
Incorrect. Capillary refill of more than 3 seconds indicates delayed perfusion, which is abnormal. Radial pulses graded 1 indicate a weak pulse, which is not within normal limits. Additionally, grips are usually graded out of 5, not 4.

D. Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal:
Incorrect. While some aspects are correct (capillary refill), the pulse grading system is incomplete here. Radial pulses should be recorded as +1 to +4, and +3 would indicate a stronger-than-normal pulse, which is not typical for normal findings. Grip strength is not fully documented here either, as it should include a scale (e.g., 5/5).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D, Evaluation.

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions that were implemented during the implementation step. In this scenario, the nurse administered pain medication and is now evaluating its effectiveness by asking the client to rate their current level of pain on a scale of 0 to 10. Based on the client's response, the nurse can determine whether the intervention was successful or whether adjustments to the plan of care are necessary.

A. Feeding B. Transferring C. Bathing D. Ambulation

Correct Answer is A

Explanation

The correct answer is choice A, feeding. Aspiration is a serious risk for clients who have difficulty swallowing or have other conditions that increase the risk of food or liquid entering the airway. During feeding, the nurse should monitor the client closely for any signs of distress or difficulty swallowing. The nurse may need to modify the consistency or texture of the food or liquid or use assistive devices such as a straw or feeding tube to reduce the risk of aspiration. Additionally, the nurse may need to position the client upright and provide support as needed during feeding. While safety observations are important during all activities, feeding is the most critical activity for clients at high risk of aspiration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Correct Answer is D

Explanation

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

Correct Answer is A

Explanation

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

Which of the following is the best example of a measurable client goal? The client will:

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?