Nokea
During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Ensure the bladder of the BP cuff surrounds 80% of their arm.
- B. Use the BP cuff on the forearm if the upper arm is not accessible.
- C. Apply the BP cuff loosely around the arm.
- D. Use a pediatric cuff for adults with small arms.
Correct Answer: A
Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.
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A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement?
- A. Acknowledge that she is supporting the arm correctly.
- B. Encourage her to keep the joint covered to maintain warmth.
- C. Reinforce the need to grip directly under the joint for better support.
- D. Instruct her to grip directly over the joint for better motion.
Correct Answer: A
Rationale: Acknowledging that the client's wife is supporting the arm correctly is the appropriate nursing action in this scenario. By doing so, the nurse reinforces correct technique and promotes confidence. Choice B is incorrect as the issue is not about maintaining warmth. Choice C is incorrect as gripping directly under the joint is not necessary in this case. Choice D is incorrect as instructing to grip directly over the joint may not provide the best support for passive range-of-motion exercises.
During a neurologic examination, which assessment should a nurse perform to test a client's balance?
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
Correct Answer: A
Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.
A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection, the nurse plans to arrange to increase the client's intake of:
- A. Vitamin C and Zinc
- B. Vitamin B12 and Calcium
- C. Vitamin D and Iron
- D. Vitamin A and Potassium
Correct Answer: A
Rationale: The correct answer is A: Vitamin C and Zinc. Vitamin C is essential for collagen synthesis, which is important for wound healing. Zinc plays a crucial role in immune function and also aids in wound healing. Vitamin B12 and Calcium (Choice B) are not directly associated with wound healing properties. Vitamin D and Iron (Choice C) are important for overall health but are not specifically targeted for wound healing. Vitamin A and Potassium (Choice D) do not have direct wound healing properties and are not the best choices to promote wound healing and fight infection.
During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?
- A. Wearing gloves during the procedure
- B. Using a sterile solution
- C. Irrigating from the inner to the outer canthus
- D. Positioning the client's head properly
Correct Answer: A
Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.