the nurse will use which technique of assessment to determine the presence of crepitus swelling and pulsations
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NCLEX-RN

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1. Which technique of assessment will the healthcare provider use to determine the presence of crepitus, swelling, and pulsations?

Correct answer: A

Rationale: Palpation involves using the sense of touch to assess various characteristics such as texture, temperature, moisture, organ location and size, as well as detecting swelling, pulsations, vibrations, rigidity, crepitus, lumps, masses, and tenderness or pain. In this scenario, the healthcare provider would utilize palpation to physically feel for crepitus, swelling, and pulsations. Inspection primarily relies on visual assessment, percussion involves assessing through palpable vibrations and audible sounds, and auscultation uses the sense of hearing. Therefore, the correct answer is palpation for assessing the presence of crepitus, swelling, and pulsations.

2. Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:

Correct answer: B

Rationale: Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.

3. After taking the vital signs for your patient and finding them to be normal, what should you do next?

Correct answer: D

Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.

4. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

Correct answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

5. A healthcare provider attempts to plug in a sequential compression device when they notice a tingling sensation in their hands while touching the cord. What is the next action of the healthcare provider?

Correct answer: C

Rationale: Feeling a tingling sensation when touching an electrical cord is a warning sign that the device may be malfunctioning. This sensation indicates a potential electrical current leak, which could pose a risk of harm. The correct action is to immediately discontinue the use of the device and send it to the maintenance department for inspection. Continuing to use the device without addressing the issue could lead to electric shock or fire hazards. Trying to plug the device into a different outlet does not address the underlying problem of potential device malfunction. Notifying the supervisor about the risk of an electrical fire is important, but the immediate action should be to stop using the device and have it inspected by maintenance professionals. Therefore, the best course of action is to discontinue the device and ensure it is checked thoroughly before further use.

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