Nokea
A nurse is planning to collect data about the abdomen of a client who reports 'stomach pain.' Which of the following actions should the nurse take first?
- A. Auscultate.
- B. Percuss.
- C. Inspect.
- D. Palpate.
Correct Answer: C
Rationale: Inspection is always the first step in an abdominal assessment to observe for any abnormalities before auscultation and palpation.
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A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
- A. Unbroken skin with un-blancheable erythema
- B. Full-thickness tissue loss extending to underlying support structures
- C. A shallow, ruptured or intact skin blister without slough
- D. A deep crater without visible bone, tendon, or muscle
Correct Answer: D
Rationale: Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but without exposed bone or muscle.
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
- A. Atelectasis
- B. Rales
- C. Rhonchi
- D. Pneumothorax
Correct Answer: A
Rationale: Atelectasis causes absent breath sounds in lung bases due to alveolar collapse.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B because even though the client is unconscious, research has shown that individuals in such states may still have some level of awareness. Talking to the client can provide comfort, stimulate brain activity, and maintain a sense of connection. Choices A, C, and D are incorrect because they do not address the potential benefits of talking to the unconscious client. A deflects the question, C dismisses the partner's concern, and D praises the AP but does not explain the rationale behind talking to the client.
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Decreased heart rate
- B. Dyspnea
- C. Increased blood pressure
- D. Thready pulse
Correct Answer: D
Rationale: The correct answer is D: Thready pulse. Hypovolemia, or low blood volume, leads to decreased blood flow, resulting in a thready pulse due to decreased stroke volume. A: Decreased heart rate is not typically associated with hypovolemia as the body may try to compensate by increasing heart rate. B: Dyspnea may occur in hypovolemic shock, but it is not a specific manifestation of hypovolemia. C: Increased blood pressure is not a typical finding in hypovolemia, as the blood pressure tends to drop due to decreased fluid volume. Thus, D is the correct choice as it directly correlates with the pathophysiology of hypovolemia.