The student nurse is performing an assessment of the client's peripheral vascular system with the experienced nurse's guidance
Which of the following actions by the student nurse indicate that the student nurse requires further education? Standard Text: Select all that apply. 1. The student nurse continues to assess the client while the client is in a flat, supine position. The client's respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips.
2. The student nurse requests that the client remove all undergarments prior to putting the gown.
3. The client left her socks on and the student nurse assesses the client's pedal pulses over the socks.
4. The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination.
5. The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the client's room for this assessment.
1,2,3,4
Rationale 1: The student nurse continues to assess the client while the client is in a flat, supine position. The client's respiratory rate increases to 26 breaths per minute and the client becomes dusky around the mouth and lips. The student nurse should pay careful attention to how well the client tolerates certain positions during the assessment. At this point, the student nurse should sit the client up to allow the client to breathe better.
Rationale 2: The student nurse requests that the client remove all undergarments prior to putting the gown . The client can leave on undergarments for this assessment.
Rationale 3: The client left her socks on and the student nurse assesses the client's pedal pulses over the socks. Socks should be removed prior to assessing the client's feet. Pulses, skin temperature, skin color, quality of sensation, and capillary refill should be assessed and this would be extremely difficult to assess while the client's socks are on her feet.
Rationale 4: The client is wearing multiple rings and bracelets. The student nurse states that she may leave them on during the examination. The client should take off her jewelry. Pulses may difficult to palpate around bracelets.
Rationale 5: The student nurse takes a blood pressure cuff, Doppler, and stethoscope into the client's room for this assessment. These pieces of equipment are required to perform this assessment.
You might also like to view...
A nurse caring for a client who has had cardiac surgery must understand how pulmonary artery pressure is monitored. What is important about pulmonary artery pressure?
A) Aids in early treatment of right-sided congestive heart failure B) Aids in the early treatment of fluid imbalances C) Assesses right-sided heart pressures D) Assesses left atrial heart pressures
The nurse is evaluating a school-age child's ability to crutch walk so that no weight is placed on an injured leg. Which walking technique indicates that teaching has been effective?
A) Walking gait B) Two-point gait C) Single-crutch support gait D) Three-point swing-through gait
The white blood cell count (WBC) of a client with systemic lupus erythematousus (SLE) shows a shift to the left. Which of the following is a priority nursing diagnosis for this client?
1. Ineffective Health Maintenance 2. Impaired Skin Integrity 3. Ineffective Coping 4. Ineffective Protection
What will the nurse most likely assess in the client diagnosed with a systemic infection?
1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities