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A client with a terminal illness is being cared for by a nurse. Which of the following findings indicates that the client's death is imminent?
- A. Cold extremities
- B. Increased appetite
- C. Elevated blood pressure
- D. Increased level of consciousness
Correct Answer: A
Rationale: Cold extremities are a common sign observed in clients nearing death. This occurs due to decreased blood circulation as the body's systems begin to shut down. Cold extremities indicate poor perfusion and reduced function of vital organs. Increased appetite (Choice B) is not typically seen in clients approaching death; instead, a decreased appetite is more common. Elevated blood pressure (Choice C) is not a typical finding in clients nearing the end of life, as blood pressure tends to decrease. An increased level of consciousness (Choice D) is also not indicative of imminent death, as clients near death often experience decreased level of consciousness or become unresponsive.
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A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
- A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
- B. Adjust the machine settings.
- C. Clean the machine to ensure accuracy.
- D. Increase the frequency of the readings.
Correct Answer: B
Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.
When interviewing the parents of a child with asthma, what information about the child's environment should be gathered most importantly?
- A. Household pets
- B. New furniture
- C. Lead-based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: When assessing a child with asthma, it is crucial to gather information about potential triggers in their environment. Household pets, such as cats or dogs, are common triggers for asthma attacks due to pet dander and saliva. This information is essential to identify if exposure to pets at home could be exacerbating the child's asthma symptoms. Choices B, C, and D are less relevant in the context of asthma triggers. New furniture, lead-based paint, and plants like cactus are not typically primary triggers for asthma attacks compared to common allergens like pet dander.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?
- A. Asks relevant questions regarding the dressing change.
- B. States he will be able to complete the wound care regimen.
- C. Demonstrates the wound care procedure correctly.
- D. Has all the necessary supplies for wound care.
Correct Answer: C
Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: The correct answer is D: 'Improve team morale.' Self-scheduling allows staff more control over their work hours, which can lead to increased job satisfaction, autonomy, and a sense of ownership over their schedules. This, in turn, fosters a positive work environment, enhances collaboration among team members, and boosts morale. Choices A, B, and C are incorrect because while self-scheduling may indirectly contribute to improved quality of care, decreased staff turnover, and minimized overtime payouts, the primary benefit in this context is the positive impact on team morale.
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
- B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse
Correct Answer: C
Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.