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A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The nurse should observe the palms of the hands to assess for cyanosis in a client with dark skin because this area is less pigmented and cyanosis is easier to detect. Palms have thinner skin and blood vessels are closer to the surface, making it more likely to show changes in color due to decreased oxygen levels. The sacrum, shoulders, and areas of trauma may not accurately reflect cyanosis in dark-skinned individuals due to the differences in skin pigmentation and thickness. By focusing on the palms, the nurse can accurately assess for cyanosis and provide appropriate care.
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The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A because when setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come in contact with the solution, remains sterile. Placing the cap sterile-side up prevents contamination and maintains the integrity of the sterile field.
Choices B, C, and D are incorrect. Placing sterile gauze over spilled solution does not address the primary concern of maintaining sterility. Holding the bottle in the center of the sterile field or with the label facing away from the palm does not directly impact the sterility of the solution. Therefore, they are not the best actions to take when pouring the sterile solution during wound irrigation.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?
- A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.
- B. Determine the reasons why the client is refusing to use the incentive spirometer.
- C. Document the client’s refusal to participate in health restorative activities.
- D. Administer a pain medication to the client.
Correct Answer: B
Rationale: The correct answer is B: Determine the reasons why the client is refusing to use the incentive spirometer. This is the priority because understanding the client's concerns or barriers to using the spirometer allows the nurse to address them effectively, promote the client's recovery, and prevent complications such as pneumonia. Requesting a respiratory therapist (A) can be helpful, but understanding the client's reasons comes first. Documenting refusal (C) is important but does not address the immediate need to assess and intervene. Administering pain medication (D) may provide temporary relief but does not address the root cause of refusal.