Exhibits

The client with a cast must have a neurovascular assessment every hour for the first 24 hours and then every 4 to 8 hours after the cast has dried. Assessment of the skin, movement, sensation, pulses, pain and capillary refill are areas of concern.

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Use your thumbnail and press the nailbed proximal to the injury

Pressure placed on the nailbed should cause blanching (pale)

Capillary refill is measured in seconds

Normal should be within 3 seconds or 5 in the older adult

Answer and Explanation

Correct Answer : B,C,D,E

A. Capillary refill is not the time it takes to return to the client's normal color after releasing pressure
B. Use your thumbnail and press the nailbed proximal to the injury: This is the correct technique for assessing capillary refill. You should press on the nailbed until it blanches and then release the pressure.
C. Pressure placed on the nailbed should cause blanching (pale): When pressure is applied to the nailbed, it should turn pale. This is known as blanching.
D. Capillary refill is measured in seconds: The time it takes for the nailbed to return to its normal color is measured in seconds.
E. Normal should be within 3 seconds or 5 in the older adult: A normal capillary refill time is generally considered to be within 3 seconds. However, in older adults, it may take up to 5 seconds for the nailbed to return to its normal color.

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Correct Answer is B

Explanation

A. Giving the client water to drink might help produce more urine, but it does not address the immediate issue of potential bladder distention, which can cause discomfort and urinary retention.
B. Evaluating the client for bladder distention is the priority action. The symptoms of lower abdominal discomfort and difficulty urinating suggest possible urinary retention, which could be due to an enlarged prostate or other obstructive issues. Assessing for bladder distention will help determine if the bladder is full and if further interventions, such as catheterization, are needed.
C. Instructing the client to try urinating again may not be effective if the client is experiencing urinary retention, and it doesn't address the underlying issue.
D. Sending the few drops of urine for evaluation could provide some information but does not address the potential problem of bladder distention or retention.

Correct Answer is []

Explanation

Potential Condition:

Lobar pneumonia

Actions to Take:

Assess for prolonged expiration - This can help determine if there is an obstructive component affecting the airflow, which is common in pneumonia.
Inspect the chest for lag on the affected side - This can help identify reduced movement due to lung involvement or fluid in the lung area.

Parameters to Monitor:

Crackle - Crackles (rales) can indicate fluid in the alveoli, which is characteristic of pneumonia.
Cyanosis - Monitoring for cyanosis can help assess the severity of hypoxemia and overall respiratory function.

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Naxlex Comprehensive Predictor Exams

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

A male client arrives at the clinic for a follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?