During a general survey, which assessment finding would be the nurse's highest priority to address?

Patient is unable to move their extremities

Patient is guarding their abdomen

Patient is leaning forward with shortness of breath

Patient is sitting upright and appears relaxed

Answer and Explanation

The Correct Answer is C

Rationale:

A. This is a significant finding that may indicate a neurologic deficit such as stroke or spinal cord injury. While urgent, it is not immediately life-threatening unless associated with respiratory compromise. Nursing priority is determined by airway, breathing, circulation (ABCs) first.

B. Guarding suggests pain, possibly from abdominal pathology such as peritonitis, appendicitis, or internal bleeding. This requires prompt assessment, but unless it is causing airway or breathing compromise, it is secondary in priority.

C. This indicates respiratory distress, which is a potentially life-threatening condition. Shortness of breath compromises oxygenation, making it the highest priority according to the ABCs framework. The nurse should immediately assess airway, oxygen saturation, respiratory effort, and be prepared to provide supplemental oxygen or other interventions.

D. This finding indicates a stable and non-urgent condition. There is no immediate risk to airway, breathing, or circulation.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Rationale:

Temperature: Worsened. Increased from 38.2°C to 38.6°C, indicating a slight rise in fever.
Pulse oximetry: Improved. Oxygen saturation improved from 85% to 95% after oxygen therapy and interventions.
Respiratory rate: Improved. Rate decreased from 32/min to 22/min, showing reduced work of breathing.
Blood pressure: Unchanged. BP remained stable at 112/56 mm Hg.
Mucous membrane color: Improved. Color changed from pale to pink, indicating improved oxygenation and perfusion.

A. On the top of the foot between the extensor tendons of the first and second toes B. On the medial side of the ankle, behind the medial malleolus C. On the inside of the wrist, proximal to the thumb D. On the lateral side of the neck, near the sternocleidomastoid muscle

Correct Answer is A

Explanation

Rationale:

A. The dorsalis pedis pulse is palpated on the dorsum (top) of the foot, just lateral to the extensor hallucis longus tendon, between the first and second toes. This pulse represents the continuation of the anterior tibial artery and provides important information about peripheral circulation to the foot and lower extremity. It is frequently assessed in patients with conditions such as peripheral arterial disease, diabetes, or vascular compromise. Assessing the dorsalis pedis pulse helps determine the adequacy of blood flow, detect arterial obstruction, and monitor changes in perfusion over time. A strong, palpable pulse indicates good arterial perfusion, whereas a weak or absent pulse may signal ischemia or arterial blockage, requiring further evaluation.

B. This is the location of the posterior tibial pulse, not the dorsalis pedis. The posterior tibial pulse is palpated behind the medial malleolus (inner ankle) and is also used to assess circulation to the foot, particularly the plantar surface. While both pulses are important in assessing peripheral circulation, they are anatomically distinct.

C. This describes the radial pulse, which is located on the lateral aspect of the wrist near the thumb. The radial pulse is commonly used to assess heart rate, rhythm, and peripheral perfusion to the hand but is not related to the dorsalis pedis pulse or lower extremity circulation.

D. This corresponds to the carotid pulse, which is used to assess central circulation. It is particularly important in emergency situations such as cardiac arrest or shock but does not provide information about peripheral arterial flow in the lower extremities.

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During a general survey, which assessment finding would be the nurse's highest priority to address?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Where is the dorsalis pedis pulse located on the human body?

Correct Answer is A

Explanation

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