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?

Determine the client's most recent hemoglobin level.

Document the presence of nailbed clubbing.

Administer a PRN prescription for oxygen.

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

Answer and Explanation

The Correct Answer is B

A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.

B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.

C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.

D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.

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Correct Answer is A

Explanation

A. Fetal growth and gestational age. Ultrasound during pregnancy is commonly used to assess fetal growth, development, and gestational age. It allows healthcare providers to monitor the health and progress of the pregnancy, as well as detect any potential issues or abnormalities.

B. Lecithin-sphingomyelin ratio. This ratio is typically assessed in amniotic fluid samples to predict fetal lung maturity, but it's not the primary reason for a routine ultrasound during pregnancy.

C. Chromosomal abnormalities. While some prenatal screening tests, such as nuchal translucency ultrasound or cell-free DNA testing, can help assess the risk of chromosomal abnormalities, a routine ultrasound is not primarily conducted for this purpose.

D. Sex and size of the infant. While ultrasound can reveal the sex of the baby and provide estimates of fetal size, these are secondary to the primary goal of assessing fetal growth and gestational age.

A. Question the client about the frequency of falls in recent months. B. Request to have the client lie as still as possible for the assessment. C. Assist the client with clarifying values about end-of-life care options. D. Ask the client how often episodes of sundowning are experienced.

Correct Answer is A

Explanation

A. Question the client about the frequency of falls in recent months: Falls are a common concern in older adults. Assessing the frequency of falls helps identify potential safety risks and mobility issues. It provides valuable information about the client’s functional status and balance.

B. Request to have the client lie as still as possible for the assessment: While assessing functional status, it is essential to observe the client’s mobility and ability to perform activities of daily living (ADLs). Having the client lie still would not provide relevant information about their functional abilities.

C. Assist the client with clarifying values about end-of-life care options: While discussing end-of-life care is important, it is not directly related to assessing functional status. This action is beyond the scope of a functional assessment.

D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to increased confusion, agitation, or behavioural changes in older adults during the late afternoon or evening. While relevant to overall well-being, it is not specifically related to functional assessment.

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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

Gestational Ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting the ultrasound is to obtain which information?

Correct Answer is A

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Correct Answer is A

Explanation

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