In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Document the presence of nailbed clubbing.

Consult with a podiatrist to trim the client's toenails.

Determine the client's most recent hemoglobin level.

Administer a PRN prescription for oxygen.

Answer and Explanation

The Correct Answer is A

A.   Nailbed clubbing is characterized by an increased angle between the nail and the nailbed, typically greater than 180 degrees. An angle of 200 degrees is consistent with clubbing, which can be a sign of chronic respiratory or cardiovascular conditions, such as chronic lung diseases, congenital heart defects, or other systemic conditions.
B.   Consulting with a podiatrist to trim toenails is important for foot care but is not directly related to the finding of nailbed clubbing. The angle of the nailbed is more indicative of a systemic issue rather than a local foot care problem. Therefore, this action does not address the underlying concern suggested by the angle of 200 degrees.
C.   While anemia or other blood conditions can affect the nails, the specific finding of a nailbed angle of 200 degrees is more indicative of clubbing rather than issues typically associated with hemoglobin levels. Therefore, while monitoring hemoglobin is important for overall health, it is not the immediate priority in response to the finding of nailbed clubbing.
D.   Administering oxygen might be necessary if the client is experiencing symptoms of hypoxia or has a condition affecting oxygenation. However, the finding of nailbed clubbing itself does not immediately necessitate oxygen therapy. Oxygen administration should be based on specific symptoms or clinical indications of hypoxia rather than the nailbed angle alone.

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Correct Answer is B

Explanation

A. Chronic Obstructive Pulmonary Disease (COPD) can lead to decreased lung function and abnormalities in lung expansion. However, COPD typically results in a more generalized decrease in lung expansion and breath sounds, rather than pronounced unilateral inequality. While COPD can cause irregularities in lung expansion, it is less likely to cause significant unilateral differences in lung expansion.
B. Unequal lung expansion is a key sign of a collapsed lung, or pneumothorax. When a lung collapses, the affected side will show reduced or absent expansion compared to the unaffected side. This is because the collapsed lung cannot expand properly during inhalation, leading to noticeable differences in breath sounds and lung movement on physical examination.
C. If the client's lungs were functioning normally, one would expect to observe symmetrical lung expansion. Unequal lung expansion is not a normal finding and usually indicates some form of pathology or abnormality in the lung or thoracic cavity. Normal lung function should result in even expansion of both lungs.
D. Chronic lung infections, such as tuberculosis or severe pneumonia, might cause abnormalities in lung sounds or localized lung issues, but they are less likely to cause pronounced unilateral differences in lung expansion. While they can affect lung function, they typically do not cause the same degree of unilateral expansion issues as a pneumothorax would.

A. Compare the skin turgor of the client's upper and lower leg. B. Observe the specific location and appearance of the ulceration. C. Note any change in the color of the ulcer when the leg is moved. D. Measure the degree of joint range of motion in the extremity.

Correct Answer is B

Explanation

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

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In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

Correct Answer is B

Explanation

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Correct Answer is B

Explanation

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