Nokea
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: B
Rationale: Nail polish, especially dark colors, can block the pulse oximeter sensor, affecting accuracy.
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The client is at risk for developing ___ as evidenced by the client's ___
- A. Infection
- B. WBC count
Correct Answer: A,B
Rationale: A: Chemotherapy lowers immunity, increasing infection risk. B: Decreased WBC count (4,000/mm³) indicates leukopenia.
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: A positive Chvostek's sign (twitching of facial muscles when tapping the facial nerve) is associated with hypomagnesemia; assumed as C due to incomplete options.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
The findings in the client's medical record indicate ___ and ___.
- A. Hyperglycemia
- B. Dehydration
Correct Answer: A,B
Rationale: Hyperglycemia: Symptoms of lethargy, thirst, and frequent urination with parenteral nutrition suggest elevated glucose levels. Dehydration: Thirst and frequent urination indicate fluid loss, a risk with parenteral nutrition if not balanced.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. Tell me your expectations about activities related to the end-of-life.
- B. You can provide the name of a spiritual support person we can contact for you.
- C. You can allow your family to visit as often as you wish.
- D. We can talk to the provider about incorporating nonpharmacological pain management in your care.
Correct Answer: A
Rationale: Asking about expectations establishes a foundation for personalized end-of-life care planning.