Nokea
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: A positive Chvostek's sign (twitching of facial muscles when tapping the facial nerve) is associated with hypomagnesemia; assumed as C due to incomplete options.
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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 has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: B
Rationale: Nail polish, especially dark colors, can block the pulse oximeter sensor, affecting accuracy.
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.
- A. Encourage the client to splint the abdomen when coughing.
- B. Administer acetaminophen.
- C. Administer ondansetron.
- D. Remind the client to use the incentive spirometer five times per hr.
- E. Encourage the client to cough and deep breathe.
- F. Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer: A,D,E,F
Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. I understand that you decided not to receive blood products.
- B. You need to talk with your doctor about this.
- C. Not receiving blood will slow down your recovery.
- D. Why are you refusing to receive blood products?
Correct Answer: A
Rationale: Acknowledging the decision respects the client’s autonomy.
The client is at risk for ___ as evidenced by the client's ___
- A. Aspiration
- B. Dysphagia
Correct Answer: A,B
Rationale: A: Dysphagia increases aspiration risk. B: Food stuck in mouth and hoarseness indicate swallowing difficulty.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.