Nokea
A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?
- A. The client takes a 20-min nap each afternoon.
- B. The client has gained 4.5 kg (10 lb) in the past month.
- C. The client is taking a poetry class.
- D. The client takes a walk for 1 hr each day.
Correct Answer: B
Rationale: Sudden weight gain can be a sign of ineffective coping, such as emotional eating.
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A nurse is caring for a client who has just learned he will need exploratory surgery the next day. As the nurse contributes to the preoperative teaching plan, which of the following actions should she take?
- A. Reinforce information at the client's level of understanding.
- B. Notify the client's family of the plan of care.
- C. Describe the surgery and what the client will experience postoperatively.
- D. Reassure the client that the surgery rarely has any negative outcomes.
Correct Answer: A
Rationale: Providing information at the client's level of understanding ensures comprehension and informed decision-making.
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
- A. Cracks in oral mucous membranes
- B. Poor skin turgor
- C. Tachycardia
- D. Excessive pulmonary secretions
Correct Answer: C
Rationale: Tachycardia can indicate oxygen toxicity. Other symptoms include confusion and restlessness. Pulmonary secretions are expected in pneumonia, not a sign of toxicity.
A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. From this information, the nurse should identify that the client is receiving which of the following oxygen concentrations?
- A. 0.28
- B. 0.36
- C. 0.5
- D. 0.7
Correct Answer: A
Rationale: A nasal cannula at 2 L/min delivers approximately 28% oxygen concentration. Higher values correspond to mask or higher flow rates.
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 interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?
- A. Arrange to complete the data collection with only the client and a translator present.
- B. Ask the client's partner to translate questions and answers for the client.
- C. Record the partner's answers to the questions and complete the assessment.
- D. Ask the partner to allow the client to provide her own answers to the nurse's questions.
Correct Answer: A
Rationale: A professional translator ensures accuracy, maintains confidentiality, and reduces potential biases from family members.