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A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Use the Face Legs Activity Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain.
- B. Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm.
- C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.
- D. Palpate the client's abdomen before auscultating bowel sounds.
Correct Answer: B
Rationale: The correct answer is B: Ensure the bladder or the blood pressure cuff surrounds 50% of the client's arm. This is the correct physical assessment technique because proper cuff placement is essential for accurate blood pressure measurement. Placing the cuff around 50% of the arm circumference ensures that the blood pressure reading is not falsely elevated or decreased. Incorrect choices: A: Using the FLACC pain rating scale is relevant for pain assessment, but not a physical assessment technique. C: Obtaining an apical heart rate by auscultating at the third intercostal space left of the sternum is incorrect as the fifth intercostal space at the midclavicular line is the correct location. D: Palpating the client's abdomen before auscultating bowel sounds is incorrect as bowel sounds should be auscultated first to prevent stimulating peristalsis.
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A nurse is caring for a client who has a terminal illness, and the client's partner indicates effective coping. The nurse should recognize that which of the following statements is an indication of effective coping?
- A. I am not worried because I will have hope that he will be okay.
- B. I am relying on support from our family during this time.
- C. We can plan our family reunion once he recovers and comes home.
- D. We don't see any reason to start discussing funeral arrangements right now.
Correct Answer: B
Rationale: The correct answer is B: "I am relying on support from our family during this time." This statement indicates effective coping because it acknowledges the importance of seeking and utilizing support from family members, which can help reduce feelings of isolation and provide emotional strength. By relying on family support, the client's partner is demonstrating a healthy coping mechanism that promotes resilience and emotional well-being during a challenging situation.
Choice A is incorrect because relying solely on hope without acknowledging the need for support may not address the partner's emotional needs effectively. Choice C is incorrect as it demonstrates denial of the terminal illness and avoidance of the current reality. Choice D is incorrect as it suggests avoidance of discussing important end-of-life decisions, which can hinder effective coping and planning.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client's refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. The nurse's priority is to assess why the client is refusing the treatment to address the underlying issue. By understanding the client's reasoning, the nurse can provide appropriate interventions and education to encourage compliance, ensuring optimal recovery. Requesting a respiratory therapist (A) may be helpful but does not address the client's refusal directly. Documenting the refusal (C) is important but does not actively address the issue. Administering pain medication (D) may provide temporary relief but doesn't address the root cause of refusal.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are visual fields (D) and visual acuity (E). Visual fields evaluate peripheral vision, important for detecting obstacles and hazards. Impaired visual acuity can affect depth perception and balance, increasing fall risk. Lacrimal apparatus (A) assesses tear production, not directly related to fall risk. Pupil clarity (B) and appearance of bulbar conjunctivae (C) are more related to eye health but do not directly assess fall risk in older adults.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrist before applying the restraints.
- B. Evaluate the client's circulation every 8 hr after application.
- C. Remove the restraints every 4 hr to evaluate the client's status.
- D. Secure the restraint ties to the bed's side rails.
Correct Answer: A
Rationale: The correct answer is A: Pad the client's wrist before applying the restraints. This is important to prevent pressure injuries and ensure the client's comfort and safety. Padding helps distribute pressure and reduces the risk of skin breakdown. Choices B, C, and D are incorrect. B is not recommended as it is essential to monitor circulation frequently, not just every 8 hours. C is incorrect because restraints should not be removed without a valid reason due to the risk of injury or harm to the client. D is also wrong as restraints should be secured to parts of the bed frame, not side rails, to prevent the client from using them to injure themselves or others.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.