Nokea
A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct Answer: B
Rationale: The correct answer is B: Earlobe. The nurse should apply the pulse oximeter probe to the earlobe in this scenario because the client's hands have edema, making finger placement less reliable for accurate readings. Thickened toenails also suggest poor circulation in the toes, making toe placement less accurate. The earlobe provides a good peripheral site for accurate oxygen saturation measurement, as it has good blood flow and is less affected by edema or circulation issues. Placing the probe on the skin fold may lead to erroneous readings due to variations in skin thickness and perfusion. Therefore, the earlobe is the most suitable and reliable location for obtaining an accurate oxygen saturation measurement in this situation.
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A nurse is caring for a client whose partner asks to speak with the nurse. The client's partner relates that she is concerned because her partner abuses alcohol and has difficulty maintaining employment. Which of the following responses should the nurse make?
- A. If I were you, I would contact a support group.
- B. I'm so sorry to hear about this.
- C. I suggest you talk with the hospital chaplain about your concern.
- D. What have you done in the past to cope with this issue?
Correct Answer: D
Rationale: Exploring the partner's past coping strategies encourages problem-solving and emotional support.
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.
A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?
- A. Reiki
- B. Aromatherapy
- C. Acupuncture
- D. Yoga
Correct Answer: D
Rationale: Yoga combines physical postures, breathing exercises, and meditation to reduce stress and promote well-being.
A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.