Nokea
A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?
- A. 4+
- B. 3+
- C. 2+
- D. 1+
Correct Answer: B
Rationale: A 6-mm indentation corresponds to 3+ pitting edema, indicating moderate to severe fluid retention.
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A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?
- A. Blood pressure
- B. Cyanosis
- C. Nausea
- D. Petechiae
Correct Answer: C
Rationale: Subjective data are information reported by the client, such as symptoms or feelings. Nausea is subjective because the client experiences and reports it. Blood pressure, cyanosis, and petechiae are objective data that can be measured or observed directly by the nurse. Blood pressure is a vital sign, cyanosis is a physical finding, and petechiae are skin manifestations. Therefore, they are not subjective data. By understanding the distinction between subjective and objective data, the nurse can accurately assess and document the client's health status.
A nurse is collecting data from a client's skin. Which of the following actions should the nurse take to assess skin turgor?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size red or purple spots.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: The correct answer is D: Grasp a fold of skin on the client's forearm or near the sternum. This method assesses skin turgor by evaluating how quickly the skin returns to its normal position after being pinched. Adequate skin turgor indicates good hydration status, as hydrated skin will snap back promptly. If the skin remains elevated or "tents," it may indicate dehydration. Choice A involves palpation, which assesses skin temperature and texture but not turgor. Choice B involves assessing edema, not skin turgor. Choice C describes petechiae, which are indicative of bleeding disorders. Overall, choice D is the most appropriate for assessing skin turgor accurately.
A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
- A. pH 7.31
- B. pH 7.39
- C. pH 7.48
- D. pH 7.50
Correct Answer: A
Rationale: The correct answer is A: pH 7.31. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to decreased pH. Normal pH range is 7.35-7.45. pH 7.31 indicates acidosis. Choice B is within the normal range, C and D are alkalotic, and E, F, G are not provided. pH 7.31 is the most accurate representation of respiratory acidosis in this scenario.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A - Excessive laxative use can lead to constipation by causing dependency on laxatives. B - Ignoring the urge to defecate can disrupt normal bowel habits. C - Inadequate fluid intake can result in hard stools and difficulty passing them. Choices D and E are incorrect because increased fiber in the diet and increased activity are actually recommended interventions to alleviate constipation.
A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?
- A. Does not eat meat and dairy products at the same meal.
- B. Does not eat birds of prey.
- C. Refrains from eating snacks between meals.
- D. Does not eat shellfish.
Correct Answer: B
Rationale: Halal dietary laws prohibit the consumption of birds of prey, as they are considered impure.