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A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client's history and assessment?
- A. Identify the client's needs
- B. Start intravenous fluids
- C. Notify the provider
- D. Conduct a neurological assessment
Correct Answer: A
Rationale: Identifying the client's needs is essential to prioritize further interventions.
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A nurse is reviewing the health history of an older adult who has a hip fracture. The nurse should identify what is a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct Answer: B
Rationale: Urinary incontinence is a risk factor for skin breakdown and pressure injuries.
A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct Answer: D
Rationale: Eye contact, personal space, and touch are cultural variables that can affect communication.
A nurse is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the nurse use?
- A. A wheelchair
- B. A stand-assist lift
- C. A transfer belt
- D. A slide board
Correct Answer: B
Rationale: A stand-assist lift is appropriate for patients who can bear partial weight and have upper body strength.
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over the top of blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct Answer: A
Rationale: Applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue.
A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased BUN
- C. Increased hematocrit
- D. Decreased urine specific gravity
Correct Answer: C
Rationale: An increased hematocrit level indicates dehydration or fluid volume deficit.