Nokea
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Oral temperature elevated at 0800.
- C. Episiotomy approximated, 3 cm (1.18 in) in length.
- D. Client drank adequate amounts of fluid with meals.
Correct Answer: C
Rationale: Documenting episiotomy details is critical for assessing postpartum healing and infection risk.
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A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client is wearing nail polish.
- B. The client has an elevated hemoglobin level.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: A
Rationale: Nail polish can block light in pulse oximetry, leading to inaccurate low readings.
Nurses' Notes
Day 1:
The client is receiving intermittent tube feedings via a nasogastric tube.
Abdomen is soft, nondistended.
Head of client's bed is positioned to 30° pH of gastric aspirate 4.0
Gastric residual volume is 50 mL Day 2:
Abdomen is distended. Client reports nausea and is coughing.
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Nurses' Notes
Day 2:
Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL
pH of gastric aspirate 4.5 Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.
Choices
Nurses' Notes Day 2:
Abdomen is distended. Client reports nausea and is coughing
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
A. Distended abdomen
B. Reports nausea and coughing
C. Gastric residual volume
D. Heart rate 110/min
E. Respiratory rate 24/min
F. pH of gastric aspirate 4.5
G. Temperature 37° C (98.6° F)
A nurse is assisting in the care of a client. Select the findings in the client's medical record that require further action by the nurse.
- A. Distended abdomen
- B. Reports nausea and coughing
- C. Gastric residual volume 550 mL
- D. Heart rate 110/min
- E. Respiratory rate 24/min
- F. pH of gastric aspirate 4.5
- G. Temperature 37° C (98.6° F)
Correct Answer: A,B,C,D,E
Rationale:
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client has poorly fitting dentures.
- B. The client verbalizes regret about never marrying.
- C. The client is sedentary throughout most of the day.
- D. The client has no living family.
Correct Answer: C
Rationale: Sedentary behavior heightens risks like DVT and cardiovascular issues, making it the priority.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will empty my drainage bag once a day.
- B. I will apply antiseptic ointment to the tip of my penis.
- C. I will keep the drainage bag below the level of my waist.
- D. I will clamp the tube when I go for a walk.
Correct Answer: C
Rationale: Keeping the bag below waist level prevents urine backflow, reducing infection risk.