A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Palpate the area behind the ankle bone.

Use the pads of the fingers to feel for the pulse.

Compare the pulse strength with the other leg.

Assess for any swelling or tenderness

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.

Choice B rationale

Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.

Choice C rationale

Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.

Choice D rationale

Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.

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Correct Answer is ["325"]

Explanation

Step 1 is to determine the total volume of fluid to be infused in the first 8 hours. According to the Parkland formula for fluid resuscitation, half of the prescribed volume is administered in the first 8 hours. Thus:

Total fluid for the first 8 hours = 5,200 mL ÷ 2 = 2,600 mL.

Step 2 is to calculate the infusion rate in mL/hr for the first 8 hours. Divide the total volume for the first 8 hours by the total time in hours:

Infusion rate = 2,600 mL ÷ 8 hr = 325 mL/hr.

Final calculated answer: 325 mL/hr.

A. Silvery, white scales. B. Intense pain. C. Unilateral lesions. D. Serous drainage

Correct Answer is A

Explanation

Choice A rationale

Silvery, white scales are a characteristic finding in psoriasis. Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, leading to the buildup of scales and red patches on the skin.

Choice B rationale

Intense pain is not typically associated with psoriasis. While psoriasis can cause discomfort and itching, it is not usually described as intensely painful.

Choice C rationale

Unilateral lesions are not characteristic of psoriasis. Psoriasis typically presents with symmetrical lesions on both sides of the body.

Choice D rationale

Serous drainage is not a common finding in psoriasis. Psoriasis lesions are usually dry and scaly rather than exudative. .

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A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["325"]

Explanation

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

Correct Answer is A

Explanation

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply)

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