The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?
Assess the forearm and hand for infection
Assess the lower extremities
Assess the dorsalis pedis pulses
None of the above
The Correct Answer is B
A. Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B. Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C. Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D. None of the above is incorrect because assessing the lower extremities is the next logical step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Resonance is a normal percussion sound heard over healthy lung tissue.
B. Tactile fremitus refers to the palpable vibration felt when a patient speaks and is normal in areas of healthy lung tissue.
C. Bronchovesicular sounds are normal breath sounds heard over the mainstem bronchi and are considered normal.
D. Rhonchi are adventitious sounds (abnormal) heard in conditions like bronchitis and would not be considered normal.
E. Crackles are also abnormal breath sounds often heard in conditions such as pneumonia or heart failure.
Correct Answer is B
Explanation
A. Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B. Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C. Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D. Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.
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