Nokea
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Basilar lung sounds that are diminished in the left lung.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Capillary refill of 2 seconds in the lower right foot.
- D. Active bowel sounds in the lower right quadrant.
Correct Answer: A
Rationale: Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome. In this case, the nurse should document the assessment that is not within normal limits, which is 'Basilar lung sounds that are diminished in the left lung.'
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The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
The healthcare provider prescribes ear drops to an adult client with an ear infection.Which exacting should the nurse follow?
- A. Swab and shake bottle before administering the drops.
- B. Administer the drops with the head tilted upright.
- C. Lower the edge of the dropper into the canal of the ear.
- D. Keep the patient in supine position to administer the drops
Correct Answer: D
Rationale: When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops. This position allows the medication to flow into the ear canal and reach the site of infection.
When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
- A. Tap the feet forwards and backwards.
- B. Bend the arm by flexing the ulna to the humerus.
- C. Turn the head to the right and left.
- D. Extend the arm at the side and rotate in circles.
Correct Answer: B
Rationale: To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus. Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.