Nokea
A nurse is assisting in interviewing a client who is being admitted from a long-term care facility. In which of the following situations should the nurse ask a closed-ended question?
- A. Determining if the client is eating a well-balanced diet
- B. Asking the client about his receptiveness to the transfer
- C. Determining how the client completes his ADLs
- D. Asking if the client took his medications this morning
- E. *
Correct Answer: D
Rationale: Closed-ended questions are useful for obtaining specific, factual information, such as whether the client took their medications.
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A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?
- A. Atrial gallop
- B. Ventricular gallop
- C. Closing of the atrioventricular valves
- D. Closing of semilunar valves
Correct Answer: B
Rationale: The correct answer is B: Ventricular gallop. An S3 heart sound is indicative of rapid ventricular filling during diastole, which is commonly associated with heart failure. This sound occurs during the early phase of diastole when the ventricles are filled rapidly due to increased pressure in the atria. The S3 sound is heard immediately after S2 (closure of semilunar valves) when blood is rushing into the ventricles. Atrial gallop (choice A) is not associated with the S3 sound. The closing of the atrioventricular valves (choice C) is part of the normal heart sounds and does not produce an S3 sound. Similarly, the closing of semilunar valves (choice D) occurs during S2 but does not cause an S3 sound. Therefore, the correct answer is B as it directly relates to the pathophysiology of an S3 heart sound.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous low-pitched gurgling sounds heard over the trachea and bronchi. These sounds are typically caused by the movement of air through narrowed airways due to secretions or inflammation. Crackles (B) are discontinuous, popping sounds typically heard during inspiration and caused by fluid in the alveoli. Wheezing (C) is a high-pitched musical sound heard on expiration and caused by narrowed airways. Friction rub (D) is a grating, rubbing sound heard during inspiration and expiration and is typically associated with inflammation of the pleura.
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
- A. Increase the client's oral fluid intake.
- B. Initiate humidification therapy.
- C. Encourage the client to cough and deep breathe.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: The correct action is to raise the head of the bed (Choice D) first. This helps improve ventilation and oxygenation by optimizing lung expansion and reducing the work of breathing. Elevating the head of the bed promotes better oxygen exchange in pneumonia patients. Increasing oral fluid intake (Choice A) may be beneficial but not the priority in this scenario. Humidification therapy (Choice B) may help with secretions but does not directly address the oxygenation concern. Encouraging cough and deep breathing (Choice C) is important for lung hygiene but should come after ensuring adequate oxygenation.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
- A. Discontinue the enema.
- B. Lower the height of the solution bag.
- C. Continue the enema and reassure the client.
- D. Pause the enema and give the client pain medication.
Correct Answer: B
Rationale: Correct Answer: B - Lower the height of the solution bag.
Rationale: Lowering the height of the solution bag will decrease the flow rate of the enema, which can help alleviate the mild cramping the client is experiencing. This adjustment can make the procedure more tolerable for the client without needing to discontinue it entirely. It is important to address the client's discomfort while ensuring the effectiveness of the enema.
Summary of other choices:
A: Discontinuing the enema may not be necessary if the client's discomfort can be managed with a simple adjustment.
C: Continuing the enema without addressing the client's discomfort may lead to increased distress.
D: Pausing the enema and giving pain medication is not the initial intervention for mild cramping and may not be necessary if a simple adjustment can alleviate the discomfort.