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A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
- A. Wait 30 min and return to measure the client's oral temperature.
- B. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.
- C. Document the inability to obtain an accurate reading of the client's oral temperature.
- D. Proceed to measure the client's oral temperature.
Correct Answer: A
Rationale: The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.
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A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
A nurse is caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A nurse is evaluating the 24-hr I&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?
- A. Intake 2,500 mL, output 500 mL
- B. Intake 2,400 mL, output 2,500 mL
- C. Intake 1,200 mL, output 700 mL
- D. Intake 800 mL, output 2,100 mL
Correct Answer: B
Rationale: A fluid intake close to output indicates balance. Excess output or retention suggests dehydration or overload.
A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The correct answer is A: Metabolic acidosis. The pH is low (acidosis) and the HCO3- is also low, indicating a primary metabolic acidosis. The low PaCO2 (respiratory alkalosis compensation) further supports metabolic acidosis. Other choices are incorrect because B: Respiratory acidosis would have a high PaCO2, C: Metabolic alkalosis would have a high HCO3-, and D: Respiratory alkalosis would have a low PaCO2 with a high pH.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
- A. Crackles
- B. Rhonchi
- C. Stridor
- D. Wheezes
Correct Answer: D
Rationale: Wheezes are high-pitched musical sounds heard on expiration and indicate narrowed airways, commonly found in asthma patients.