A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?
Document information directly from a textbook.
Copy previous nursing assessment.
Document their findings.
Seek clarification from a more experienced nurse.
The Correct Answer is D
A. Documenting information directly from a textbook is incorrect because textbooks provide general guidelines, not client-specific data. The student's assessment findings should be based on the actual client’s condition.
B. Copying a previous nursing assessment is incorrect and unethical. Each assessment must be conducted independently to ensure accurate and up-to-date client care.
C. Documenting findings without confidence in their accuracy can lead to errors in client care. If the student is uncertain, verification is necessary before documentation.
D. Seeking clarification from a more experienced nurse is correct. If a student nurse is unsure of their assessment findings, they should ask a preceptor or experienced nurse for guidance to ensure accuracy and safe client care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The groin is correct because skin folds in obese clients are prone to excessive moisture, which increases the risk of fungal or bacterial infections such as intertrigo. The nurse should inspect these areas for redness, irritation, or signs of infection.
B. The heels are at risk for pressure injuries but are not typically associated with excessive moisture or diaphoresis.
C. The elbows are not a common site for moisture retention and are not a priority for inspection in this case.
D. The toes can be prone to fungal infections (e.g., athlete’s foot), but the primary concern in an obese client with diaphoresis is the skin folds, particularly in the groin and under the breasts.
Correct Answer is D
Explanation
A. A macule is a flat, non-palpable skin lesion. The described lesion is raised, making macule incorrect.
B. A nodule is a deeper, larger, and firmer lesion (>0.5 cm in diameter). The lesion described is too small to be classified as a nodule.
C. A pustule is a pus-filled lesion. The description does not mention purulent content, ruling out pustule.
D. A papule is correct. A papule is a small, raised, solid lesion that is <1 cm in diameter, which fits the description of the bump on the boy’s neck.
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