While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Deep, continuous pain in the calf muscles.

Painful symptoms alleviated by warmth.

Cool, pale skin below the knees.

Decreased pain when legs are elevated.

Answer and Explanation

The Correct Answer is D

A. Deep, continuous pain in the calf muscles:
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth:
Painful symptoms alleviated by warmth are more characteristic of arterial insufficiency, such as in peripheral arterial disease (PAD), rather than venous insufficiency.

C. Cool, pale skin below the knees:
Cool, pale skin below the knees is also more suggestive of arterial insufficiency rather than venous insufficiency. Arterial insufficiency often presents with decreased blood flow to the extremities, resulting in coolness and pallor.

D. Decreased pain when legs are elevated:
This is the correct answer. Venous insufficiency typically results in symptoms such as aching, tired legs, and swelling, which worsen with prolonged standing but improve with leg elevation. This is due to the reduction in venous pressure when the legs are elevated, which helps alleviate symptoms associated with venous congestion and stasis.

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Correct Answer is A

Explanation

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

A. Elevate the head of the client's bed immediately. B. Use the bell of the stethoscope to auscultate again. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants.

Correct Answer is C

Explanation

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

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While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Correct Answer is C

Explanation

Rationale:

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

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?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

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