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 a fever.
- B. The client has an elevated hemoglobin level.
- C. The client is wearing a ring.
- D. The client is wearing nail polish.
Correct Answer: D
Rationale: Nail polish can interfere with pulse oximetry readings by absorbing light.
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A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink an average of 2,000 milliliters of water daily.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink two hot cups of coffee each morning.
Correct Answer: B
Rationale: Opioids can cause constipation, impairing bowel elimination.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. I understand that you decided not to receive blood products.
- C. You need to talk with your doctor about this.
- D. Why are you refusing to receive blood products?
Correct Answer: B
Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. There has been too much complaining about these changes.
- B. Please, try to wait a little longer. Things will get better soon.
- C. So, you are upset about all of the recent changes on the unit?
- D. Why don't you just file a formal complaint with Human Resources?
Correct Answer: C
Rationale: Reflecting the AP's feelings encourages open communication.