Nokea
A client comes to the clinic complaining of severe facial pain. In order to collect subjective data from the client, it is MOST important for the nurse to
- A. obtain the client's vital signs.
- B. interview the client.
- C. inspect the face for grimacing.
- D. administer pain medication.
Correct Answer: B
Rationale: subjective data is collected in the health history or interview
You may also like to solve these questions
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
The nurse is caring for a client after an ileostomy. The nurse would be MOST concerned if which of the following was observed?
- A. The ileostomy functions without daily irrigations.
- B. The stoma appears to be tight, and there is a decreased amount of stool.
- C. A small amount of mucus is seen around the anal area.
- D. There is weight gain of 5 lb over a three-week period of time.
Correct Answer: B
Rationale: important to report these findings to the physician; may indicate an obstruction or stoma stricture
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.
The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate?
- A. Maintain and improve the quality of oxygenation.
- B. Improve the status of ventilation.
- C. Increase oxygenation of peripheral circulation.
- D. Correct the bicarbonate deficit.
Correct Answer: B
Rationale: to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
The nurse is caring for a client with a history of hypothyroidism.
- A. Which symptom is expected in a client with untreated hypothyroidism?
- B. Weight loss and irritability.
- C. Cold intolerance and fatigue.
- D. Tachycardia and heat intolerance.
- E. Diarrhea and restlessness.
Correct Answer: B
Rationale: Cold intolerance and fatigue are classic symptoms of hypothyroidism due to slowed metabolism. Weight loss, tachycardia, and diarrhea are associated with hyperthyroidism.