Nokea
A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct Answer: B
Rationale: A pulse deficit indicates ineffective cardiac contractions and the presence of cardiac dysrhythmias.
You may also like to solve these questions
A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. Which of the following actions should the nurse take first after obtaining the client's history and assessment?
- A. Identify the client's needs
- B. Start intravenous fluids
- C. Notify the provider
- D. Conduct a neurological assessment
Correct Answer: A
Rationale: Identifying the client's needs is essential to prioritize further interventions.
A nurse is preparing a client for transfer to another unit. Which finding does the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct Answer: D
Rationale: All findings are important for ensuring continuity of care in the transfer report.
A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct Answer: C
Rationale: Older adults typically experience a decrease in skin elasticity, which can contribute to various skin-related issues.
A nurse is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the nurse use?
- A. A wheelchair
- B. A stand-assist lift
- C. A transfer belt
- D. A slide board
Correct Answer: B
Rationale: A stand-assist lift is appropriate for patients who can bear partial weight and have upper body strength.
A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct Answer: A
Rationale: Bladder distention indicates the inability to empty the bladder, which can be a sign of catheter occlusion.