Nokea
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.
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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?
- A. 4+
- B. 3+
- C. 2+
- D. 1+
Correct Answer: B
Rationale: A 6-mm indentation corresponds to 3+ pitting edema, indicating moderate to severe fluid retention.
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
- A. Red mucous membranes
- B. Jugular vein distention
- C. Skin tenting
- D. BP 178/90 mm Hg
Correct Answer: C
Rationale: Skin tenting is a hallmark sign of dehydration due to decreased skin elasticity. Jugular vein distention and high BP indicate fluid overload.
A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage of the apical lung segments. Which of the following statements by the client should the nurse identify as understanding of the teaching?
- A. I will sit up on the side of the bed with my legs dangling.
- B. I will turn on my left side with my legs elevated higher than my chest.
- C. I will position myself on my back with my head lower than my feet.
- D. I will lie on my abdomen with pillows under my stomach and chest.
Correct Answer: D
Rationale: Prone positioning with pillows under the chest promotes postural drainage of apical lung segments. Other positions are ineffective.
A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?
- A. Assign another nurse to be responsible for obtaining capillary glucose levels.
- B. Verify that the newly licensed nurse attended the staff education class about capillary glucose levels.
- C. Repeat the capillary glucose levels.
- D. Recheck the next scheduled capillary glucose level immediately following the nurse's.
Correct Answer: C
Rationale: The correct answer is C: Repeat the capillary glucose levels. This action should be taken to confirm the accuracy of the initial results. By repeating the test, the charge nurse can determine if the inaccuracy was due to a procedural error or if there is an issue with the equipment. This step ensures that the client receives proper care based on accurate information.
Assigning another nurse (choice A) does not address the root cause of the inaccurate results. Verifying attendance at an education class (choice B) is not as immediate or relevant as repeating the test. Rechecking the next scheduled level (choice D) without verifying the accuracy of the initial result may lead to continued inaccuracies in care.
A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea has been traditionally used in Chinese medicine to aid digestion by stimulating the production of digestive enzymes and reducing bloating and gas. This can be particularly beneficial for an older adult recovering from a bowel obstruction as it can help ease the digestive process and prevent further complications. Additionally, ginger has anti-inflammatory properties, which can also be helpful in reducing inflammation in the digestive tract.
Other choices are incorrect:
A: To regulate blood pressure - While ginger may have some benefits for heart health, its primary role in this scenario is to aid digestion, not regulate blood pressure.
C: To enhance the immune system - While ginger may have some immune-boosting properties, the primary reason for the client's request in this case is to aid digestion.
D: To reduce inflammation - While ginger does have anti-inflammatory properties, the main purpose of the client's request is to aid digestion rather than specifically targeting inflammation.