Nokea
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
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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 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 love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
- A. Temperature 37.5° C (99.5° F)
- B. Client is difficult to arouse.
- C. Respiratory rate 10/min
- D. Pulse oximetry 88% on room air
- E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg
- F. Heart rate 61/min
Correct Answer: B,C,D
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 preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.