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The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally.

Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally.

Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical.

Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal.

Answer and Explanation

The Correct Answer is B

A. Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally:
Incorrect. Capillary refill should be less than 2-3 seconds for normal findings; less than 5 seconds would be too long and could indicate poor perfusion. Radial pulses graded +4 are not typical and suggest a bounding pulse, which could indicate an abnormal condition. Grips graded 10/10 is not the standard grading system; typically, grips are graded out of 5.

B. Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally:
Correct. This option uses proper terminology. Capillary refill of less than 3 seconds is normal, radial pulses graded +2 are normal, and grips are appropriately graded on a 5-point scale, with 5/5 being the normal strength.

C. Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical:
Incorrect. Capillary refill of more than 3 seconds indicates delayed perfusion, which is abnormal. Radial pulses graded 1 indicate a weak pulse, which is not within normal limits. Additionally, grips are usually graded out of 5, not 4.

D. Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal:
Incorrect. While some aspects are correct (capillary refill), the pulse grading system is incomplete here. Radial pulses should be recorded as +1 to +4, and +3 would indicate a stronger-than-normal pulse, which is not typical for normal findings. Grip strength is not fully documented here either, as it should include a scale (e.g., 5/5).

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Correct Answer is ["59.1"]

Explanation

The patient's weight in kg would be:

130 lbs ÷ 2.2 lbs/kg = 59.09 kg

Rounded to the nearest tenth, the patient weighs 59.1 kg.

A. The wound base appears pink to red, with serous drainage, and the client's oral temperature is 99.0°F. B. The wound base appears yellow, with serosanguineous drainage, and the client's oral temperature is 100°F. C. The wound base appears red, skin is warm to touch with foul odor, and the client's oral temperature is 101.5°F. D. The wound base appears yellow, with serous drainage, and the client's oral temperature is 99°F.

Correct Answer is C

Explanation

The correct answer is choice C. Signs of a wound infection include redness, warmth, and tenderness around the wound, as well as fever, chills, and malaise. The wound base may appear yellow, indicating the presence of pus, and may have a foul odor. Serous drainage is typically clear and does not indicate infection, while serosanguineous drainage may indicate a mild infection or normal healing process. An oral temperature of 101.5°F is elevated and may indicate an infection.

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The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse needs to calculate the amount of a medication based on a patient's weight in kg. If the patient weighs 130 pounds, how many kg does the patient weigh? Round to the nearest tenth.

Correct Answer is ["59.1"]

Explanation

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

Correct Answer is C

Explanation

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

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When conducting a physical assessment of the extremities, which of the following assessments would be the most correct?

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The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?