to assess pedal pulses which arterial sites should the nurse palpate select all that apply

HESI LPN

Adult Health Exam 1

1. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)

A. Posterior tibial artery
B. Radial artery
C. External iliac artery
D. Dorsalis pedis artery

Correct answer: D

Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.

2. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

A. Temperature of 100.8Â°F
B. A pulse rate of 150 beats per minute
C. A respiratory rate of 10 breaths per minute
D. A blood pressure of 180/110

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

3. An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement?

A. Tell the client to keep her belongings because she will need them at discharge
B. Ask the client if she has had any recent thoughts of harming herself
C. Reassure the client that the antidepressant drugs are apparently effective
D. Support the client by telling her what wonderful progress she is making

Correct answer: B

Rationale: In this scenario, the nurse should ask the client if she has had any recent thoughts of harming herself. Sudden mood improvements and behavioral changes, like giving away belongings, can be concerning signs of possible suicidal ideation. Assessing for suicidal thoughts is crucial to ensure the client's safety. Choice A is incorrect as it does not address the potential risk of harm or assess for suicidal ideation. Choice C is incorrect because simply reassuring the client about the effectiveness of antidepressants does not address the immediate concern of suicidal ideation. Choice D is incorrect as it focuses on praising progress without addressing the potential risk of harm the client may pose to herself.

4. What is the function of the cervix in reproduction?

A. Accepts and interprets signals of sexual stimuli
B. Secretes mucus to facilitate sperm transport
C. Serves as the site for union of ovum and sperm
D. Receives the penis during intercourse

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

5. When using a metered-dose inhaler (MDI), which step is most important for ensuring effective medication delivery?

A. Exhale completely before using the inhaler
B. Inhale quickly while pressing down on the inhaler
C. Shake the inhaler for 10 seconds before use
D. Hold breath for 5 seconds after inhaling

Correct answer: A

Rationale: The correct step to ensure effective medication delivery when using a metered-dose inhaler (MDI) is to exhale completely before using the inhaler. This action helps create more space in the lungs for the medication to reach deeply into the airways. Inhaling quickly while pressing down on the inhaler (Choice B) may cause the medication to impact the throat rather than reaching the lungs. Shaking the inhaler for 10 seconds before use (Choice C) is important to mix the medication but not the most crucial step for effective delivery. While holding the breath for 5 seconds after inhaling (Choice D) can help the medication stay in the lungs momentarily, exhaling completely before inhalation is more critical for optimal drug deposition.