Nokea
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.
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A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene.
- A. Adjust the suction to 120 to 150 mm Hg.
- B. Apply intermittent suction while rotating the catheter.
- C. Don sterile gloves.
- D. Check the function of the suction catheter.
- E. Insert the catheter without suction.
- F. Hyperoxygenate the client.
- G. Check for secretion clearance.
Correct Answer: A,F,D,C,E,B
Rationale: Check for secretion clearance.
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 preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.
A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?
- A. Auscultate for Korotkoff's sounds.
- B. Perform a Romberg test.
- C. Check the function of cranial nerve V.
- D. Inspect for the presence of clubbing.
Correct Answer: B
Rationale: The correct answer is B: Perform a Romberg test. This test evaluates the client's ability to maintain balance with eyes closed, which is essential for safe ambulation in a client with ataxia. Auscultating for Korotkoff's sounds (A) is related to blood pressure assessment, not ambulation. Checking cranial nerve V function (C) is important for facial sensation and chewing, not directly related to ambulation. Inspecting for clubbing (D) is related to respiratory or cardiovascular conditions, not relevant to assessing ambulation.
A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory grief?
- A. A client who has recently given up a child for adoption
- B. A client who experiences traumatic amputation of an extremity
- C. A client whose son committed suicide
- D. A client who has a new diagnosis of metastatic liver cancer
Correct Answer: D
Rationale: Anticipatory grief occurs when an individual knows a loss is imminent, as in terminal cancer.