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. A positive Homan's sign indicates potential deep vein thrombosis (DVT) but is not a common or reliable indicator for chronic swelling of the feet. Bilateral swelling is less likely related to DVT and more likely to be due to systemic issues.
B. 2+ pitting edema of the ankles bilaterally directly indicates chronic swelling. This finding supports the client's statement of persistent swelling, which is characteristic of fluid retention or systemic issues affecting both feet.
C. Capillary refill greater than 3 seconds may indicate poor peripheral circulation but does not directly assess or confirm chronic swelling of the feet.
D. Weak and thready pedal pulses suggest poor blood flow but are not directly related to the symptom of chronic swelling. They indicate possible circulatory issues rather than swelling alone.

A. Perform a mental status exam to assess the client's thought processes. B. Begin to orient the client to her surroundings in the hospital room. C. Stand directly in front of the client and ask about any hearing loss. D. Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

Correct Answer is C

Explanation

A. Performing a mental status exam is important but may not be the immediate priority if the issue could be related to a more straightforward problem such as hearing loss.
B. Orienting the client to her surroundings is helpful but may not address the immediate concern of her ignoring questions, which could be due to hearing issues.
C. Standing directly in front of the client and asking about hearing loss addresses a possible issue with communication immediately. It is crucial to rule out hearing impairment before assuming other causes for the client's behavior.
D. Using a tuning fork to complete Rinne and Weber tests is a valid assessment for hearing loss but is a more specific test that may be implemented after the nurse initially assesses whether hearing loss is a potential issue.

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Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is B

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is C

Explanation

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

When evaluating a client's rectal bleeding, which findings should the nurse document?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Exhibits Heart sounds are loudest for Sl at the dropdown and for S2 at the dropdown