Nokea
A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?
- A. Decreased peripheral pulses
- B. Heart rate 108/min
- C. Respiratory rate 10 breaths/min
- D. Dilated pupils
Correct Answer: B
Rationale: The correct answer is B: Heart rate 108/min. When a client has a fever (oral temperature of 39 C), the body responds by increasing the heart rate to help circulate blood more efficiently and maintain oxygen delivery to tissues. This compensatory mechanism is known as tachycardia. Decreased peripheral pulses (A) would not be expected as the body tries to increase circulation. Respiratory rate of 10 breaths/min (C) is extremely low and not consistent with fever. Dilated pupils (D) are not directly related to fever.
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A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.
A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?
- A. Role-play
- B. Question-and-answer
- C. Discussion
- D. Return demonstration
Correct Answer: D
Rationale: The correct answer is D: Return demonstration. This teaching strategy involves the client performing the skill back to the nurse to demonstrate understanding and competence. It allows for immediate feedback and correction. Role-play (A) involves acting out a scenario, not necessarily related to skill demonstration. Question-and-answer (B) involves asking and answering questions but does not involve the client performing a skill. Discussion (C) involves exchanging ideas and opinions, not skill demonstration.
A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply.
- A. Electrical cord on floor over a walkway
- B. Demonstrates correct use of cane to ambulate
- C. Grab bar in the bathroom
- D. Diagnosis of macular degeneration
- E. Throw rugs in kitchen
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- A: An electrical cord on the floor is a tripping hazard, increasing the risk of falls.
- D: Macular degeneration affects vision, leading to difficulties in depth perception and obstacle detection, increasing fall risk.
- E: Throw rugs in the kitchen can cause slipping or tripping, posing a fall hazard.
Summary of Incorrect Choices:
- B: Demonstrating correct use of a cane indicates the client is taking precautions to prevent falls.
- C: Having a grab bar in the bathroom is a safety measure to prevent falls.
- F and G: Not provided in the question, so cannot be evaluated.
A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
- A. Place the client on a low-fiber diet
- B. Request a prescription for a mineral oil for the client
- C. Encourage the client to drink cold fluids
- D. Increase the client's fluid intake
Correct Answer: D
Rationale: The correct answer is D: Increase the client's fluid intake. This intervention helps prevent constipation by promoting hydration and softening stool. Adequate fluid intake aids in maintaining bowel motility and preventing hard stools. Low-fiber diet (A) can exacerbate constipation. Mineral oil (B) can lead to complications and should be avoided. Cold fluids (C) may cause discomfort and are not directly related to improving constipation. In summary, increasing fluid intake is the most appropriate intervention to address constipation in a client on bedrest.
A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?
- A. Muscle mass
- B. Bone density
- C. Joint flexibility
- D. Muscle strength
Correct Answer: C
Rationale: Passive range of motion exercises are performed to maintain or improve joint flexibility in clients who are unable to move their joints independently. This helps prevent contractures and stiffness. Joint flexibility allows for better mobility and reduces the risk of injury. The other choices are incorrect because: A) Muscle mass is not directly affected by passive range of motion exercises. B) Bone density is not the primary focus of passive range of motion exercises. D) Muscle strength is not the main goal of passive range of motion exercises.