Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

Beneath the lower jaw.

Anterior to the temporal bone.

Lateral to the trachea.

Above the upper jaw.

Answer and Explanation

The Correct Answer is A

A. The submandibular lymph nodes are located beneath the lower jaw, in the area where the jawbone meets the neck. This is the correct location to palpate for enlargement of these lymph nodes.
B. The temporal bone is located on the side of the head, not relevant to the location of the submandibular lymph nodes. Palpation for these nodes occurs beneath the lower jaw, not near the temporal bone.
C. Lateral to the trachea refers to the location of other lymph nodes such as the anterior cervical or supraclavicular nodes, not the submandibular nodes. Submandibular nodes are specifically beneath the jaw.
D. Above the upper jaw does not correspond to the location of the submandibular lymph nodes. These nodes are palpated beneath the lower jaw, making this option incorrect.

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Correct Answer is B

Explanation

A. The post-voided residual volume assessment is not part of a bladder retraining program but is a diagnostic tool used to assess bladder function after catheter removal. This explanation misrepresents the purpose of the procedure.
B. The post-voided residual volume assessment measures how much urine remains in the bladder after the client has voided. This measurement helps determine if the bladder is emptying properly and whether there is a need for catheter re-insertion.
C. Post-voided residual volume assessment does not stimulate the bladder to empty more completely; instead, it measures the amount of urine left in the bladder. The procedure is diagnostic rather than therapeutic.
D. The post-voided residual volume assessment is a diagnostic procedure, not an exercise in conditioning. This explanation does not accurately describe the clinical purpose of the assessment.

A. Respiratory rate 18 breaths/minute B. Heart rate 101 beats/minute C. Capillary refill 2 seconds D. Breath sounds clear and equal bilaterally E. Turban dressing is saturated with serosanguinous drainage F. Blood pressure 140/84 mm Hg G. Temperature 101.9° F (38.8° C) H. Client is awake and alert

Correct Answer is ["B","E","G"]

Explanation

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

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Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is voiding frequent small amounts 24-hours following the removal of an indwelling catheter, and a post-voided residual volume assessment is prescribed. Which explanation should the practical nurse (PN) provide to the client about why the procedure is necessary?

Correct Answer is B

Explanation

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Correct Answer is ["B","E","G"]

Explanation

The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?

Exhibits The practical nurse (PN) suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

Exhibits The practical nurse (PN) is preparing to change the turban dressing. For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the PN monitor? Select all that apply.

Which assessment finding indicates to the practical nurse that a Venturi face mask is producing the desired effect?

Exhibits Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.