Nokea
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
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A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.
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 client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.