the pulse point located on the top of the foot is
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NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. Where is the pulse point located on the top of the foot?

Correct answer: D

Rationale: The pulse point located on the top of the foot is known as the dorsalis pedis pulse point. It is situated on the arch of the foot, slightly lateral to the midline. This pulse point is commonly examined in patients with peripheral vascular problems to assess blood flow adequacy. Additionally, some individuals may not have this pulse point due to a congenital anomaly. Therefore, all the given statements are correct in relation to the dorsalis pedis pulse point, making 'All of the above' the correct answer. Choices A, B, and C are all individually valid characteristics of the dorsalis pedis pulse point, hence selecting 'All of the above' as the correct answer is appropriate.

2. The abbreviation pc is defined as ________________.

Correct answer: C

Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.

3. A patient's blood pressure is 118/82 mm Hg. The patient asks the nurse, "What do the numbers mean?"? Which is the best reply by the nurse?

Correct answer: C

Rationale: The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume. Both the systolic and diastolic blood pressure are important. Choice A is incorrect as providing a vague reassurance does not address the patient's query. Choice B is incorrect as it inaccurately describes the diastolic pressure as reflecting stroke volume, which is incorrect. Choice D is incorrect as it oversimplifies the explanation, focusing solely on the top number without providing a complete understanding of blood pressure.

4. When placing a patient in the AP position for an X-ray, what position would the patient be in?

Correct answer: D

Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.

5. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

Correct answer: B

Rationale: To effectively communicate the client's outcome goals that were met and those that were not to the LTC staff, the nurse should draw conclusions about the resolution of the current client problems. Terminal evaluation is performed to determine the client's condition at discharge, focusing on which goals were achieved and which were not. Formulating post-discharge nursing diagnoses (option A) is not the most appropriate action in this scenario as it focuses on identifying potential problems after discharge rather than evaluating achieved goals. Assessing the client for baseline data (option C) is not necessary at this point as the focus is on evaluating outcomes rather than collecting baseline data. Planning the care needed in the LTC facility (option D) is premature as this should be done on admission to the LTC facility and not during the discharge process.

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