The nurse is assessing a client's right lower extremity and notes ...

[Evvie72]

The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin?
 
  1. Fingertips.
  2. Metacarpophalgeal joints.
  3. Dorsal surface.
  4. Ulnar surface.

Question 2

While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate?
 
  1. Obtain a stethoscope with longer tubing.
  2. Ask another nurse to listen to the lung sounds.
  3. Hold the stethoscope tubing while listening to the lung sounds.
  4. Close the eyes and focus on one sound at a time.

[AISCAMPING]

Answer to Question 1

Correct Answer: 3
The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. The metacarpophalgeal joint area of the hand is used to assess for vibration, or fremitus. The ulnar surface of the hand is also used to assess for fremitus.

Answer to Question 2

Correct Answer: 4
Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. Touching the stethoscope tubing can cause additional sounds and should be avoided.

[Evvie72]

TYSM

[nguyenhoanhat]

Gracias!