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

Assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.

Rebound tenderness in both the arms and legs, skin turgor, and moisture.

Assess the measurements in centimeters of each extremity, pulses, and varicosities.

Assess pulses, strength, range of motion, percussion, odor, and edema.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. When conducting a physical assessment of the extremities, the most appropriate assessment would be to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. This comprehensive assessment can help to identify potential issues with circulation, strength, and skin integrity, and can also provide a baseline for ongoing assessments. Rebound tenderness in both the arms and legs, skin turgor, and moisture (choice B) are not typically assessed during a physical assessment of the extremities. Assessing the measurements in centimeters of each extremity, pulses, and varicosities (choice C) may be appropriate in certain situations, but it is not a comprehensive assessment of the extremities. Assessing pulses, strength, range of motion, percussion, odor, and edema (choice D) is also not a comprehensive assessment of the extremities and may not provide a complete picture of the client's condition. Therefore, the most appropriate assessment when conducting a physical assessment of the extremities is to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.

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Correct Answer is B

Explanation

A. Ask the client which language they would like the written materials.While providing written materials in the client’s preferred language is important for communication, this does not directly address the client's vision loss. It may help with understanding but does not enhance their ability to see the materials.

B. Ensure the client has access to all corrective eyewear.This is the most appropriate intervention. Ensuring that the client has access to corrective eyewear, such as glasses or contact lenses, will help maximize their remaining vision. This is a practical and supportive action for someone with moderate vision loss.

C. Speak in a loud voice directly at the patient.Vision loss does not imply hearing impairment, so speaking in a loud voice is unnecessary and could be confusing or frustrating for the client. Communication should be clear and normal in volume, not assuming a hearing deficit.

D. Place the client close to the nurse's station.Placing the client close to the nurse’s station may enhance safety and allow for quicker assistance. However, it is not specifically related to addressing the client's vision loss and may not be necessary depending on their overall condition.

A. 1 B. 4 C. 15 D. 10

Correct Answer is B

Explanation

The PCA (patient-controlled analgesia) pump is programmed to deliver a dose of 0.5 mg of morphine every 15 minutes as needed. This setup means that only 1 dose can be administered every 15 minutes, regardless of how many times the patient presses the button.

Since 60 minutes have passed, the maximum number of doses the patient could receive is calculated as follows:

60 minutes/ 15 minutes per dose= 4 doses

Even though the patient pressed the button 10 times, the pump will only deliver a dose every 15 minutes, resulting in 4 doses.

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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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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with moderate vision loss. Which intervention would be most appropriate for this client?

Correct Answer is B

Explanation

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

Correct Answer is B

Explanation

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