Nokea
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.
- A. Apical pulse
- B. Capillary refill time
- C. Lung sounds
- D. Pupillary response
- E. Skin color and temperature
Correct Answer: B,E
Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.
You may also like to solve these questions
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies
- A. destroy organisms causing disease
- B. maintain fluid balance
- C. boost the immune system
- D. increase bodily energy
Correct Answer: C
Rationale: boost the immune system. The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body's own defenses.
The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.
A client with Cushing's syndrome should be instructed to:
- A. Avoid alcoholic beverages
- B. Limit the sodium in her diet
- C. Increase servings of dark green vegetables
- D. Limit the amount of protein in her diet
Correct Answer: B
Rationale: A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.