While a nurse is assessing a 63-year-old client at the clinic, the client states, "I have always taken an evening walk, but lately, my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Which of the following should the nurse do first?

Ask about any skin color changes that occur in response to cold

Attempt to palpate the dorsalis pedis and posterior tibial pulses

Check for the presence of tortuous veins bilaterally on the legs

Assess for unilateral swelling, redness, and tenderness of either leg

Answer and Explanation

The Correct Answer is B

A. Asking about skin color changes can provide information about vascular problems like Raynaud’s phenomenon but is not the priority given the client’s symptoms.
B. Palpating the dorsalis pedis and posterior tibial pulses assesses arterial blood flow, which is crucial because the client’s symptoms suggest peripheral arterial disease (intermittent claudication). This is the priority assessment.
C. Checking for tortuous veins assesses venous insufficiency or varicose veins, which do not align with the client’s symptoms.
D. Assessing for unilateral swelling, redness, and tenderness checks for deep vein thrombosis (DVT), which is unlikely based on the pain that resolves with rest.

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Correct Answer is A

Explanation

A. Increasing dyspnea occurs due to collapsed alveoli reducing lung capacity and oxygenation.
B. Facial flushing is not typically related to atelectasis.
C. Friction rub is usually heard in pleuritis, not atelectasis.
D. Respiratory rate generally increases in response to hypoxia, so a decrease is unlikely.

A. Have the client drink 8 ounces of Coca-Cola. B. Administer 1 mg of glucagon subcutaneously. C. Administer a glucose tablet. D. Obtain a glucose reading using a finger stick

Correct Answer is D

Explanation

A. While Coca-Cola contains sugar and could raise blood glucose, it should not be given without first confirming hypoglycemia through a blood glucose reading.
B. Glucagon is typically reserved for severe hypoglycemia when the client is unconscious or unable to swallow. This client is conscious and able to communicate symptoms.
C. Administering glucose tablets is appropriate after confirming hypoglycemia, not before.
D. The client’s symptoms—anxiety, nervousness, and sweating—are classic signs of hypoglycemia. The nurse’s priority is to obtain a glucose reading via finger stick to assess the client’s current glucose level before initiating treatment.

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While a nurse is assessing a 63-year-old client at the clinic, the client states, "I have always taken an evening walk, but lately, my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Which of the following should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

While hospitalized and recovering from an episode of diabetic ketoacidosis, the client calls the nurse and reports feeling anxious, nervous, and sweaty. What is the nurse's priority action based on the client's report?

Correct Answer is D

Explanation

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