A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Femoral.

Popliteal.

Brachial.

Carotid.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.

Choice A rationale:

Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.

Choice C rationale:

Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.

Choice D rationale:

Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.

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

Choice A rationale:

Sanguineous. Sanguineous drainage is typically bright red and consists of fresh blood. It indicates active bleeding from the wound. In this case, the drainage described is not bright red but rather light red-pink, suggesting that it is not purely sanguineous.

Choice B rationale:

Serous. Serous drainage is thin, watery, and typically clear or slightly yellowish in color. It is a normal part of the wound healing process and is not indicative of active bleeding. However, the drainage described in the question is light red-pink, which is not consistent with serous drainage.

Choice C rationale:

Purulent. Purulent drainage is thick, often opaque, and can range in color from yellow to green. It indicates the presence of infection in the wound. The description of watery light red-pink drainage does not align with the characteristics of purulent drainage.

Choice D rationale:

Serosanguineous. Serosanguineous drainage is a combination of serous and sanguineous fluids. It appears as a thin, watery drainage that is pink-tinged due to the presence of a small amount of blood. This description matches the observed drainage in the question. Serosanguineous drainage is common during the initial stages of wound healing and is considered a normal part of the process.

A. Airborne. B. Contact. C. Droplet. D. Protective.

Correct Answer is B

Explanation

The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.

Choice A reason:

Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.

Choice B reason:

Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.

Choice C reason:

Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.

Choice D reason:

Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.

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

A Medical-Surgical nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

Correct Answer is D

Explanation

A nurse in the Medical-Surgical unit is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Correct Answer is B

Explanation

A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?