Nokea
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Overweight
- C. Underweight
- D. Ideal body weight
Correct Answer: B
Rationale: A BMI of 25-29.9 is classified as overweight.
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A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?
- A. History of dementia
- B. Steady gait
- C. History of gastric reflux
- D. Age of 45
Correct Answer: A
Rationale: Dementia increases confusion and fall risk, predisposing to accidents.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. BMI of 24
- B. Orthostatic hypotension
- C. Type 1 diabetes mellitus
- D. Family history of osteoporosis
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia.
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. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
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 verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: D
Rationale: Sedentary lifestyle is a priority as it poses immediate health risks like thrombosis or muscle atrophy.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma protrudes slightly from the abdomen.
- B. The stoma bleeds lightly when touched.
- C. The stoma appears dark in color.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: C
Rationale: A dark stoma suggests necrosis or ischemia, requiring urgent provider notification.