A nurse is assessing a client's lymph nodes, which assessment technique is correct?

Deep palpation using circular motion

Tapping using gentle strokes with four fingers

Lightly pinching with first two fingers

Using gentle circular motions with the pads of the fingers

Answer and Explanation

The Correct Answer is D

A. Deep palpation using circular motion is inappropriate for lymph node assessment because lymph nodes are superficial structures. Deep palpation may miss small nodes or cause discomfort and is generally reserved for assessing deeper organs, such as the liver or kidneys.

B. Tapping using gentle strokes with four fingers describes percussion, which is used to assess structures like the lungs or abdomen, not lymph nodes. Percussion does not provide information about size, consistency, mobility, or tenderness of lymph nodes.

C. Lightly pinching with first two fingers is not a standard technique and may be too rough or inaccurate to assess lymph nodes. Pinching could compress surrounding tissues and fail to detect small or tender nodes.

D. Using gentle circular motions with the pads of the fingers is the correct technique. The nurse should use the pads of the index and middle fingers to gently palpate each group of lymph nodes in a systematic sequence, assessing for size, consistency, tenderness, and mobility. This technique ensures that nodes are not missed and patient discomfort is minimized.

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Correct Answer is C

Explanation

A. While temperature is an important vital sign, it is not directly related to cardiac rhythm or dysrhythmias. Abnormal temperature may influence heart rate indirectly (e.g., fever causing tachycardia), but it is not the priority assessment for a client with known cardiac dysrhythmias.

B. Pulse oximetry measures oxygen saturation and can indicate hypoxia. Although oxygenation is important, dysrhythmias primarily affect heart rate and rhythm rather than oxygen saturation directly. It is secondary to assessing the pulse in this context.

C. The pulse is the most critical vital sign to assess in a client with a history of cardiac dysrhythmias. Evaluating the rate, rhythm, and quality of the pulse allows the nurse to identify irregularities such as tachycardia, bradycardia, skipped beats, or other arrhythmias. Dysrhythmias can lead to decreased cardiac output, hypotension, syncope, or sudden cardiac events, so prompt identification is essential for timely intervention.

D. Respiratory rate is important for overall assessment, especially if dysrhythmias compromise cardiac output, but it is not the primary indicator of cardiac rhythm issues. It is a secondary assessment compared with the pulse.

A. Respirations B. Blood pressure C. Pain D. Heart rate E. Temperature F. Oxygen saturation

Correct Answer is ["B","D"]

Explanation

A. The respiratory rate is not provided in the assessment data. Because no abnormal value is documented, respirations cannot be identified as concerning based on the available information. There is no evidence of tachypnea, bradypnea, or respiratory distress.

B. A blood pressure of 90/58 mmHg is hypotensive. In a 74-year-old client, hypotension is especially concerning because it may indicate decreased organ perfusion. Potential causes include dehydration, blood loss, sepsis, medication effects, or cardiac dysfunction. Older adults have decreased physiologic reserve, so low blood pressure increases the risk for dizziness, falls, syncope, kidney injury, and altered mental status. This finding requires immediate assessment.

C. A pain rating of 1/10 indicates minimal discomfort. This level of pain is mild and not physiologically destabilizing. It does not suggest acute distress or hemodynamic compromise and therefore is not a priority concern.

D. A heart rate of 118 beats per minute is tachycardia. Normal adult heart rate ranges from 60 to 100 beats per minute. Tachycardia in this context is concerning, especially when paired with hypotension. The elevated heart rate may represent a compensatory mechanism in response to low blood pressure in an attempt to maintain cardiac output and organ perfusion. This combination raises concern for early shock, hypovolemia, or other circulatory instability and requires prompt follow-up.

E. A temperature of 98.9°F (37.1°C) is within normal limits. There is no evidence of fever or hypothermia. This value does not indicate infection or systemic instability.

F. An oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no sign of hypoxia or respiratory compromise.

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A nurse is assessing a client's lymph nodes, which assessment technique is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client with a history of cardiac dysrhythmias. Which vital sign should the nurse prioritize when conducting the assessment?

Correct Answer is C

Explanation

Correct Answer is ["B","D"]

Explanation

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