Nokea
A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
- A. Skin turgor.
- B. Weight.
- C. Blood pressure.
- D. Lung sounds.
Correct Answer: B
Rationale: Daily weight accurately tracks fluid balance.
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After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?
- A. Offer fruit juice at least twice during both the day and evening shifts.
- B. Encourage the client to eat all of the meals that are sent.
- C. Lower the bed prior to helping the client to move up in bed.
- D. Have the client hold a pillow over the abdomen to cough and deep breathe.
Correct Answer: D
Rationale: Splinting aids breathing.
After a seven-day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. While providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. Which resource should the nurse use first in resolving the situation?
- A. Medication reference guide.
- B. Nursing unit charge nurse.
- C. Healthcare provider.
- D. Hospital pharmacist.
Correct Answer: C
Rationale: Prescriber clarifies dosage discrepancies.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Bowel incontinence.
- B. Impaired bed mobility.
- C. Fluid volume deficit.
- D. Caregiver role strain.
Correct Answer: C
Rationale: Dehydration from diarrhea is life-threatening.