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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

A. Solid, dark brown color B. Asymmetric, irregular borders C. Flat with silvery scales D. Diameter of 3 mm

Correct Answer is B

Explanation

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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