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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 is wearing a ring.
- D. The client has a fever.
Correct Answer: B
Rationale: Nail polish can block the pulse oximeter's light, leading to inaccurate oxygen saturation readings.
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A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Check the client's skin integrity every 4 hr.
- C. Tie the belt restraint to the side rail of the bed.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown prevents skin irritation and ensures proper fit per safety guidelines.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Check the client's range of motion every 6 hr.
- B. Make sure two fingers fit under the restraints.
- C. Secure the restraints with a square knot.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: B
Rationale: Ensuring two fingers fit under restraints prevents excessive tightness and maintains circulation.
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Watch television in bed.
- C. Drink a glass of milk before bedtime.
- D. Take a long walk before bedtime.
Correct Answer: C
Rationale: Milk contains tryptophan, which promotes sleep; other options may disrupt sleep patterns.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Speech-language pathologist
- B. Respiratory therapist
- C. Occupational therapist
- D. Registered dietitian
Correct Answer: A
Rationale: A speech-language pathologist specializes in evaluating and treating swallowing difficulties like dysphagia.