Nokea
A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take?
- A. Explore the client's feelings.
- B. Discuss the competency of the surgeon.
- C. Review another individual's similar surgical experience.
- D. Talk with the client's partner.
Correct Answer: A
Rationale: Encouraging the client to express their feelings provides emotional support and helps alleviate anxiety.
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A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
- A. Erythema
- B. Pallor
- C. Coolness
- D. Drainage
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice B) and coolness (choice C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.
A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take?
- A. Over articulate words to improve client understanding.
- B. Change voice volume during each sentence.
- C. Minimize background noise to decrease distractions.
- D. Sit in a chair to one side of the client.
Correct Answer: C
Rationale: Minimizing background noise enhances communication for clients with hearing loss.
A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034
- B. Bounding pulse
- C. BP 146/94 mm Hg
- D. Distended neck veins
Correct Answer: A
Rationale: The correct answer is A: Urine specific gravity 1.034. Urine specific gravity measures the concentration of solutes in the urine, and a value of 1.034 indicates highly concentrated urine, which is a sign of dehydration. When the body is dehydrated, the kidneys conserve water, leading to concentrated urine.
Choice B, a bounding pulse, is a sign of fluid volume overload rather than dehydration. Choice C, high blood pressure, is not a direct indicator of dehydration. Choice D, distended neck veins, may be seen in conditions like heart failure but are not specific to dehydration. Overall, urine specific gravity is the most direct and reliable indicator of dehydration in this scenario.
A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the ball of a finger as the puncture site
- B. Uses the side of a fingertip as the puncture site
- C. Avoids using the fingers of her dominant hand as puncture sites.
- D. Avoids using the thumbs as puncture sites
Correct Answer: B
Rationale: The correct answer is B: Uses the side of a fingertip as the puncture site. This is because the side of the fingertip has fewer nerve endings compared to the center, making it less painful for blood glucose monitoring. Choice A is incorrect as using the ball of a finger can be more painful. Choices C and D are incorrect as there is no specific reason to avoid using the fingers of the dominant hand or thumbs as puncture sites. It is important to choose a less painful site for blood glucose monitoring to encourage the client to monitor regularly.