a nurse is preparing to assess the dorsalis pedis pulse the nurse palpates this pulse by placing the fingertips in which location
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips in which location?

Correct answer: B

Rationale: The correct location to palpate the dorsalis pedis pulse is lateral to and parallel with the extensor tendon of the big toe. Choices A, C, and D describe the locations for other pulses - popliteal, posterior tibial, and femoral artery respectively. The popliteal pulse is found behind the knee, the posterior tibial pulse is located in the groove between the malleolus and the Achilles tendon, and the femoral artery is situated below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines.

2. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

Correct answer: D

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100�F should be reported to the physician as it could indicate infection.

3. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

4. A nurse sees documentation in the client's record indicating that the health care provider has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds have which aspect?

Correct answer: D

Rationale: Adventitious breath sounds are abnormal sounds that are not normally heard in the lungs. These sounds are added sounds superimposed on the breath sounds. They are caused by air colliding with secretions in the tracheobronchial passageways or when previously deflated airways pop open. Hollow sounds heard over the trachea and larynx are normal bronchial (tracheal) breath sounds, not adventitious. Rustling sounds heard over the peripheral lung fields are normal vesicular breath sounds, not adventitious. Therefore, the correct answer is that adventitious breath sounds are abnormal sounds that should not be heard in the lungs.

5. When assessing the health-related physical fitness of a client as part of a health assessment, what aspect should be the focus?

Correct answer: D

Rationale: When assessing the health-related physical fitness of a client, the primary focus should be on identifying risk factors that could predispose the client to illness or injury. Risk factors are crucial in determining an individual's overall health status and potential health outcomes. While agility, speed, and body composition are important components of physical fitness assessments, they are not the primary focus when assessing health-related physical fitness from a holistic perspective. Therefore, the correct choice is 'risk factors.'

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