The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.

The strength of the lower extremities.

The patient's sense of balance.

The presence of edema.

The range of motion of the ankle.

The status of the patient's skin turgor.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Assessing the strength of the lower extremities is one of the objectives of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action helps evaluate the muscle strength of the lower limbs, providing information about the patient's neuromuscular function.

Choice B rationale:

Assessing the patient's sense of balance is another objective of this action. Dorsiflexion and plantarflexion require coordination and balance. If the patient struggles to maintain balance while performing these movements, it could indicate issues with proprioception or neurological deficits.

Choice C rationale:

Assessing the presence of edema is not directly related to dorsiflexion and plantarflexion movements. Edema assessment typically involves inspecting and palpating specific areas of the body, such as the ankles, to check for swelling, discoloration, and pitting.

Choice D rationale:

Evaluating the range of motion of the ankle joint is a key aspect of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action allows the nurse to observe how far the patient can move their ankles, providing valuable information about joint flexibility and function.

Choice E rationale:

Assessing the status of the patient's skin turgor involves checking the skin's elasticity and hydration level, usually by pinching and observing how quickly the skin returns to its normal position. This assessment is unrelated to the dorsiflexion and plantarflexion movements and is not applicable in this context.

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Correct Answer is C

Explanation

Choice A rationale:

Ethical dilemma involves a situation in which a person is faced with conflicting moral principles, making it difficult to choose the right course of action. In this scenario, the nurse is not dealing with conflicting moral principles but rather providing information about end-of-life care options, demonstrating respect for the patient's autonomy.

Choice B rationale:

Nonmaleficence is the principle of doing no harm. While it is an important ethical principle in nursing, it does not directly apply to the situation described. The nurse is not making decisions that could harm the patient but is instead providing information and support regarding end-of-life care options.

Choice C rationale:

Autonomy refers to the right of individuals to make their own decisions about their own lives and bodies, even if those decisions are not in their best interest according to others. In this scenario, the nurse is respecting the patient's autonomy by providing information and discussing various care options, allowing the patient to make informed decisions about their end-of-life care.

Choice D rationale:

Social justice involves promoting fairness and equity in the distribution of resources and opportunities. While social justice is an important nursing value, it does not directly apply to the situation described. The nurse is primarily focused on respecting the patient's autonomy and providing information about end-of-life care options.

A. Place the probe on a finger that has slow or delayed capillary refill. B. Plan to document the pulse oximeter reading as a percent. C. Assure the reading is taken in bright light, such as sunlight or fluorescent light. D. Avoid removing dark nail polish before the reading is obtained.

Correct Answer is B

Explanation

Choice A rationale:

Placing the pulse oximeter probe on a finger with slow or delayed capillary refill can lead to inaccurate readings. Slow capillary refill indicates poor peripheral perfusion, which may affect the accuracy of pulse oximetry readings. The nurse should select a finger with normal capillary refill to obtain accurate readings.

Choice B rationale:

Documenting the pulse oximeter reading as a percent is the correct action. Pulse oximeter readings are expressed as percentages, representing the oxygen saturation level in the patient's blood. Normal oxygen saturation levels typically range from 95% to 100%. Documenting the reading in percent allows healthcare providers to monitor the patient's oxygenation status accurately.

Choice C rationale:

Assuring that the reading is taken in bright light, such as sunlight or fluorescent light, is incorrect. Bright light can interfere with the accuracy of pulse oximetry readings by causing the sensor to misinterpret external light as a pulsatile signal. To obtain accurate readings, the pulse oximeter should be used in a well-lit environment but away from direct bright light sources.

Choice D rationale:

Avoiding the removal of dark nail polish before obtaining the reading is incorrect. Dark nail polish can interfere with the pulse oximeter's ability to detect the pulsatile signal from the patient's finger, leading to inaccurate oxygen saturation readings. The nurse should advise the patient to remove dark nail polish or choose another finger without nail polish for the measurement.

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The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.What is the nurse assessing in whole, or part, with this action? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.