A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

venous insufficiency

claudication

muscle cramps

deep vein thrombosis

bruit from turbulent blood flow

Answer and Explanation

The Correct Answer is B

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

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Correct Answer is E

Explanation

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

A. Performing chest percussion on a client with atelectasis B. Auscultate lungs on a client with audible wheezing C. Taking vital signs on a male client with severe dyspnea D. Suctioning a client with hemoptysis (bloody sputum) E. Setting up a meal tray for a client with COPD

Correct Answer is E

Explanation

A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.

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A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

Correct Answer is E

Explanation

The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Correct Answer is E

Explanation

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