Nokea
A nurse is caring for a client who expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct Answer: B
Rationale: Asking the client to describe their feelings allows the nurse to understand the specific concerns and anxieties the client is experiencing.
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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 receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct Answer: B
Rationale: The nurse should first reassess the client's BP to confirm the reading before taking any further action.
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only if needed
- B. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray
- C. Keep the dressing tray on the client's bed
- D. Avoid talking during the procedure
Correct Answer: B
Rationale: If liquid comes in contact with the sterile field at any point, it is considered contaminated and unsterile, necessitating the restart of the procedure.
A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct Answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD.
A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the nurse use?
- A. Numeric rating scale
- B. Behavioral indicators)
- C. Visual analog scale
- D. Faces pain scale
Correct Answer: B
Rationale: For clients with dementia who have difficulty communicating, behavioral indicators such as increased agitation and restlessness are effective methods for assessing pain.