Which of the following should the nurse perform to assess the arterial function of the lower extremities?
Assess for pretibial edema
Palpate pedal pulses bilaterally
Allen test
Homan sign
The Correct Answer is B
A. Pretibial edema: Edema is more indicative of venous function, not arterial function.
B. Palpate pedal pulses bilaterally: Palpation of the pedal pulses is essential to assess arterial circulation in the lower extremities.
C. Allen test: This assesses arterial blood flow to the hand, not the lower extremities.
D. Homan sign: Homan sign is used (though controversial) to assess for deep vein thrombosis (DVT), which is related to venous, not arterial, function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. High-pitched, tinkling sounds: These may indicate bowel obstruction, not expected immediately after surgery.
B. Normal bowel sounds: Normal bowel sounds usually return gradually after surgery, but are unlikely within the first 24 hours.
C. Hypoactive bowel sounds: It is common to hear hypoactive or diminished bowel sounds in the first 24-48 hours after abdominal surgery due to postoperative ileus.
D. Hyperactive bowel sounds: These suggest increased peristalsis and are not typical immediately after surgery.
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
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