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A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
- A. Image A: Client sitting with legs dangling over the edge of the table and the examiner tapping below the patella with a reflex hammer.
- B. Image B: Client lying down with legs extended and the examiner tapping above the patella with a reflex hammer.
- C. Image C: Client sitting with legs crossed while the examiner taps the patella with a reflex hammer.
- D. Image D: Client standing with knees slightly bent while the examiner taps the patella with a reflex hammer.
Correct Answer: A
Rationale: The correct answer is A because the image depicts the correct technique for eliciting the patellar reflex. When assessing the patellar reflex, the client should be sitting with their legs dangling over the edge of the table, and the examiner should tap below the patella with a reflex hammer. This position allows for optimal relaxation of the quadriceps muscle and easy access to the patellar tendon, resulting in a more accurate reflex response.
Choice B is incorrect because tapping above the patella can lead to an inaccurate response as it does not target the patellar tendon directly. Choices C and D are incorrect as they involve incorrect client positions that do not facilitate the proper assessment of the patellar reflex.
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
- A. During the admission process.
- B. As soon as the client's condition is stable.
- C. During the initial team conference.
- D. After consulting with the client's family.
Correct Answer: A
Rationale: Correct Answer: A. During the admission process.
Rationale: Discharge planning should start early to ensure a smooth transition. During admission, the nurse can assess the client's needs, resources, and support system. This allows time to address any potential barriers to discharge and create a comprehensive plan. Starting discharge planning later may lead to delays and inadequate preparation for the client's transition. Initiating discharge planning during the admission process promotes continuity of care and helps prevent readmissions.
Summary of Other Choices:
B: Waiting until the client's condition is stable may delay discharge planning and increase the risk of complications during the transition.
C: Waiting for the initial team conference may result in missed opportunities to address discharge needs promptly.
D: Involving the client's family is important, but discharge planning should start early to ensure all aspects of the plan are considered and implemented effectively.
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
- A. Temperature 100°F
- B. Oxygen saturation 88%
- C. Blood pressure 130/80 mmHg
- D. Heart rate 98 beats/min
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system. Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up. Choices E, F, and G are not relevant findings in this scenario.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45° angle.
- B. Administer the medication to the client's non-dominant arm.
- C. Pull the client's skin layer downward at administration.
- D. Massage the injection site after administration.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication with the needle at a 45° angle. Enoxaparin is a medication that is typically administered subcutaneously. Injecting at a 45° angle helps ensure proper absorption of the medication into the subcutaneous tissue, avoiding potential intramuscular injection. Administering to the non-dominant arm (B) or pulling the skin downward (C) are not necessary steps for administering enoxaparin. Massaging the injection site after administration (D) is contraindicated as it can increase the risk of bruising or bleeding.