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NurseDive Free Nursing Practice Question
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
A. Check the capillary refill every 4 hrs
Check the capillary refill every 4 hrs IncorrectThe nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs
Compare the pedal pulses every 4 hrs CORRECTThe nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their lower extremities.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Check the capillary refill every 4 hrs Incorrect
The nurse should check capillary refill distally every 4 hr for a client whops elastic bandages on their lower extremities.
B. Compare the pedal pulses every 4 hrs CORRECT
The nurse should compare the pedal pulses bilaterally every week to check for adequate circulation for a client who has elastic bandages on their
lower extremities.
Similar Questions
A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?
A. The reduced muscle tone relaxed the low muscles
The reduced muscle tone had relaxed the law muscles CORRECTPrior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.
B. "That happens when a person gets close to death
"That happens when a person gets close to death INCORRECTThis automatic response is nontherapeutic and does not address the family member's question
C. "I can apply a chin strap to help hold the mouth closed
"I can apply a chin strap to help hold the mouth closed INCORRECT Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed
Full Explanation
A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.
B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question
C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed
A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?
A. A Provide privacy for the client
Provide privacy for the client CORRECTThe nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment
B. B Expose hair of the body as a
Expose hair of the body as an INCORRECTTo promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected
Full Explanation
A. Provide privacy for the client CORRECT
The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment
B. Expose hair of the body as an INCORRECT
To promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected
A nurse is preparing to administer enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify the correct placement of the NG tube?
A. Check the pH of the gastric aspirate.
Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B. Observe the color of the gastric aspirate after adding blue dye to the formula.
Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C. Auscultate over the epigastrium.
Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D. Measure the length of the inserted NG tube.
Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.
Full Explanation
A: Correct. Checking the pH of the gastric aspirate is the most reliable method to verify the correct placement of the NG tube. Gastric aspirate typically has an acidic pH (pH < 5), indicating that the tube is in the stomach.
B: Observing the color of the gastric aspirate after adding blue dye to the formula is not a standard or recommended method for verifying NG tube placement.
C: Auscultating over the epigastrium may help to identify the presence of air in the stomach, but it does not confirm that the NG tube is correctly placed in the stomach or the intestines.
D: Measuring the length of the inserted NG tube can help determine the distance from the nose to the stomach, but it does not ensure correct placement in the stomach.