Nokea
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.
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A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
- A. Explain to the client what is about to happen.
- B. Make sure the room temperature is cool.
- C. Provide music as an environmental distraction.
- D. Inform the client that the provider will examine sensitive areas first.
Correct Answer: A
Rationale: The correct answer is A: Explain to the client what is about to happen. This is important to ensure the client's understanding and cooperation during the physical examination. By explaining the procedure, the nurse can reduce the client's anxiety and build trust. This communication also promotes client autonomy and respects their dignity. As for the other choices: B (Make sure the room temperature is cool) is not directly related to preparing the client for the physical examination. C (Provide music as an environmental distraction) may not be appropriate for all clients and may not address the client's emotional needs. D (Inform the client that the provider will examine sensitive areas first) may cause unnecessary anxiety without providing a clear understanding of the examination process.
A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?
- A. Transparent
- B. Wet-to-dry
- C. Dry, sterile
- D. Antimicrobial
Correct Answer: A
Rationale: Transparent dressings protect stage I pressure ulcers while allowing for visualization of the wound.
A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
- A. Use a cotton-tipped applicator to remove cerumen.
- B. Pull the pinna downward and backward.
- C. Aim the probe posteriorly in the direction of the eardrum.
- D. Insert the probe with a circular motion.
Correct Answer: C
Rationale: The correct answer is C because aiming the probe posteriorly in the direction of the eardrum allows for accurate tympanic temperature measurement. This ensures that the infrared sensor is positioned correctly to capture the heat emitted from the tympanic membrane. Choice A is incorrect as removing cerumen is not necessary for temperature measurement. Choice B is incorrect as pulling the pinna downward and backward is not required for tympanic temperature measurement. Choice D is incorrect as inserting the probe with a circular motion may cause discomfort or injury to the ear canal.