Nokea
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Gloves ensure infection control. C: Side prick is correct technique. E: Iodine disinfects; A risks hemolysis, D impedes flow.
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Nurses' Notes
Day 1:
The client is receiving intermittent tube feedings via a nasogastric tube.
Abdomen is soft, nondistended.
Head of client's bed is positioned to 30° pH of gastric aspirate 4.0
Gastric residual volume is 50 mL Day 2:
Abdomen is distended. Client reports nausea and is coughing.
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Nurses' Notes
Day 2:
Abdomen is distended. Client reports nausea and is coughing Gastric residual volume 550 mL
pH of gastric aspirate 4.5 Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
Select the findings in the client's medical record that require further action by the nurse. To deselect a finding, click on the finding again.
Choices
Nurses' Notes Day 2:
Abdomen is distended. Client reports nausea and is coughing
Gastric residual volume 550 mL pH of gastric aspirate 4.5
Vital Signs
Day 2:
Temperature 37° C (98.6° F) Blood pressure 114/68 mm Hg Heart rate 110/min Respiratory rate 24/min
Pulse oximetry 90% on room air
A. Distended abdomen
B. Reports nausea and coughing
C. Gastric residual volume
D. Heart rate 110/min
E. Respiratory rate 24/min
F. pH of gastric aspirate 4.5
G. Temperature 37° C (98.6° F)
A nurse is assisting in the care of a client. Select the findings in the client's medical record that require further action by the nurse.
- A. Distended abdomen
- B. Reports nausea and coughing
- C. Gastric residual volume 550 mL
- D. Heart rate 110/min
- E. Respiratory rate 24/min
- F. pH of gastric aspirate 4.5
- G. Temperature 37° C (98.6° F)
Correct Answer: A,B,C,D,E
Rationale:
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Severe wheezing
- B. Rhinitis
- C. Small, raised vesicles over the body
- D. Itching of the skin
Correct Answer: A
Rationale: Severe wheezing suggests anaphylaxis, a life-threatening reaction requiring immediate intervention.
A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of the following indicates the type of face mask the nurse should use to deliver the client a 90% oxygen concentration?
- A. Simple face mask
- B. Nasal prongs
- C. Non-rebreather mask
- D. Nasal cannula
Correct Answer: C
Rationale: A non-rebreather mask delivers up to 90-100% oxygen, ideal for raising saturation.
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. Client instructed on self-care needs.
- B. Oral temperature elevated at 0800.
- C. Episiotomy approximated, 3 cm (1.18 in) in length.
- D. Client drank adequate amounts of fluid with meals.
Correct Answer: C
Rationale: Documenting episiotomy details is critical for assessing postpartum healing and infection risk.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has tuberculosis
- C. A client who is HIV-positive
- D. A client who has had varicella
Correct Answer: D
Rationale: Prior varicella exposure prevents shingles transmission, making this roommate safe.