While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

Observe the color of the extremity.

Notify the healthcare provider of the assessment finding.

Discontinue elevating the client's affected extremity.

Document the neurovascular assessment as normal.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because observing the color of the extremity provides additional information about circulation and potential complications such as compartment syndrome.

Choice B reason: Notifying the healthcare provider is necessary if there are abnormal findings.

Choice C reason: Discontinuing elevation is not necessary unless there are signs of compromised circulation.

Choice D reason: Documenting the assessment as normal comes after completing a thorough assessment.

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

Explanation

Choice A reason: Limiting computer screen time is good general advice but is not specific to preventing blindness from glaucoma.

Choice B reason:

The correct answer is b) because following the prescribed regimen for eye drops helps manage intraocular pressure, which is crucial for preventing optic nerve damage in glaucoma.

Choice C reason:

The correct answer is c) because reporting any changes in vision can help detect progression of glaucoma early and allow for timely intervention.

Choice D reason: Maintaining a diet high in vegetables is good for overall health but is not directly related to preventing blindness from glaucoma.

Choice E reason:

The correct answer is e) because regular eye pressure checks help monitor the effectiveness of treatment and prevent progression of glaucoma.

A. Obtain a specimen of urethral drainage for culture. B. Observe the perineal area for a chancre-like lesion. C. Identify all sexual partners in the last four days. D. Assess for perineal itching, erythema, and excoriation.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because obtaining a specimen for culture is essential to diagnose a potential sexually transmitted infection and guide appropriate treatment.

Choice B reason: Observing for a chancre-like lesion may be part of the assessment but is not the first step.

Choice C reason: Identifying sexual partners is important for contact tracing but is secondary to obtaining a diagnostic specimen.

Choice D reason: Assessing for itching and erythema is important but not the immediate priority.

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While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is A

Explanation

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While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?