The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Secreting bile

Absorbing electrolytes

Secreting digestive enzymes

Absorbing large amounts of water

Answer and Explanation

The Correct Answer is D

A. The colon does not secrete bile; bile is produced by the liver and stored in the gallbladder.
B. The colon does absorb electrolytes, but its primary function is water absorption, which helps form solid stool.
C. The colon does not secrete digestive enzymes; enzyme secretion occurs primarily in the stomach and small intestine.
D. The colon's primary function is absorbing large amounts of water, which helps maintain fluid balance and form feces. Disruptions, such as in colon cancer, can lead to diarrhea or constipation.

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Correct Answer is A

Explanation

A. The client's ability to change position is correct. The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Limited mobility increases the risk for pressure injuries.
B. A history of integumentary disorders is not part of the Braden Scale assessment. The scale focuses on current risk factors rather than past dermatologic conditions.
C. Skin pigmentation is not a factor in pressure ulcer risk assessment. However, in clients with darker skin, early signs of pressure injuries may be harder to detect due to lack of visible blanching.
D. Medications are not directly included in the Braden Scale. While some medications (e.g., steroids) can increase pressure injury risk, the Braden Scale does not specifically assess them.

A. The use of two middle fingers lightly applied to area along the thumb side of the wrist. B. Application of firm pressure on the wrist area along the side of the fifth digit. C. Application of the bell of the stethoscope to the antecubital area of the upper extremity. D. Use of the thumb and index finger to obliterate the area along the thumb side of the wrist.

Correct Answer is A

Explanation

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

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The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

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Naxlex Comprehensive Predictor Exams

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

Correct Answer is A

Explanation

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

Correct Answer is A

Explanation

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