Nokea
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.
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A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?
- A. Irrigate the eye daily with 0.9% sodium chloride irrigation solution.
- B. Dim the lights in the room.
- C. Instill ophthalmic ointment into the lower lid.
- D. Keep the client off her left side.
Correct Answer: C
Rationale: The correct answer is C: Instill ophthalmic ointment into the lower lid. This action helps prevent corneal abrasions by keeping the eye moist and lubricated. Irrigating the eye with saline solution (choice A) may not provide adequate protection. Dimming the lights (choice B) doesn't directly address eye protection. Keeping the client off her left side (choice D) is unrelated to eye care.
A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the Seventh-Day Adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?
- A. Leavened bread
- B. Eggs
- C. Milk
- D. Caffeinated coffee
Correct Answer: D
Rationale: The correct answer is D: Caffeinated coffee. Seventh-Day Adventists typically avoid caffeine due to health beliefs. Coffee contains caffeine, which is considered a stimulant and is restricted. Leavened bread (A) is not specifically restricted. Eggs (B) and milk (C) are generally accepted. In summary, the other choices are incorrect because they are not specifically restricted by the Seventh-Day Adventist church.
A client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
- A. Bradypnea
- B. Peripheral edema
- C. Cyanosis
- D. Hypertension
Correct Answer: D
Rationale: Early signs of hypoxia include tachypnea, restlessness, and hypertension due to sympathetic nervous system activation.