Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

irregular wound borders

distinct wound borders to plantar aspect of foot

Patient reports 9 (0-10) scale to area

minimal serous drainage

+3 edema to the mid-calf

Answer and Explanation

Correct Answer : A,E

A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.

B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.

C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.

D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.

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 B

Explanation

B. This question is also inclusive as it does not assume the client's sexual orientation or relationship status. It allows the client to disclose their current relationship status, whether they are in a relationship with a partner of the same or different gender, or if they are single.

A. This question uses assumes the client's gender and sexual orientation.

C. This question assumes a heterosexual relationship and also implies traditional gender roles. It may not be inclusive as it assumes that the client has a wife and further stereotypes the role of a wife as a cook.

D. This question assumes a heterosexual relationship and may not be inclusive of clients who do not have husbands or who are in same-sex relationships. It also reinforces traditional gender roles by assuming that a husband is the primary breadwinner or has a defined occupation.

A. Reduce environmental stimuli B. Suction the oropharynx C. Assess pulse oximetry D. Administer oxygen

Correct Answer is A

Explanation

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

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

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these questions, used by the nurse, shows appropriate use of inclusive language?

Correct Answer is B

Explanation

What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Correct Answer is A

Explanation

To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Which goal is appropriate for a client who is experiencing diarrhea? The client will:

The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

The nurse explains to the client that intravenous fluid administration is used to:

The nurse is instructing family members of an immunosuppressed client who has been placed in a protective environment to wear gloves and a mask when visiting the client. The nurse is aware that this practice is important to prevent infection transmission from:

The nurse understands that the most beneficial action to take to prevent an IV from infiltrating is to:

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?