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When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

Refer the individual for further evaluation.

Check for the presence of claudication.

Consider this finding as normal, and proceed with the peripheral vascular evaluation.

Answer and Explanation

The Correct Answer is D

A. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.

B. Referral is not needed if perfusion is adequate.

C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.

D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.

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Correct Answer is D

Explanation

A. Make note of this finding: Delaying action by merely reporting the finding later may compromise patient care.

B. Prepare to remove cerumen: Sudden hearing loss is unlikely to be caused by cerumen buildup without further assessment.

C. Irrigate with rubbing alcohol: This is inappropriate and could harm the ear.

D. Notify the health care provider: Sudden sensorineural hearing loss can be a medical emergency and should be promptly evaluated by the healthcare provider.

A. Test for the Murphy sign B. Test for shifting dullness C. Perform the obturator test D. Test for the Blumberg sign E. Perform the iliopsoas muscle test F. Test for fluid wave

Correct Answer is ["C","D","E"]

Explanation

A. Murphy sign: This is used to assess for gallbladder inflammation, not appendicitis.

B. Shifting dullness: This is used to detect ascites, not appendicitis.

C. Obturator test: This test involves flexing the patient's right hip and knee and rotating the leg internally, causing pain if the appendix is inflamed.

D. Blumberg sign: This test for rebound tenderness indicates peritoneal irritation, commonly associated with appendicitis.

E. Iliopsoas muscle test: This test involves extending the right leg against resistance, which can elicit pain in cases of appendicitis.

F. Fluid wave: This is used to assess for ascites, not appendicitis.

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When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;

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Naxlex Comprehensive Predictor Exams

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Correct Answer is D

Explanation

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

The nurse is testing a patient's visual accommodation, which refers to which action?

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In performing a voice test to assess hearing, which of these actions would the nurse perform?

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The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?