Nokea
The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. BP 142/88 mmHg
- B. 2+ edema of fingers and hands
- C. Radial pulse volume is +3
- D. Capillary refill time is 2 seconds
Correct Answer: B
Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.
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When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.
When making the bed of a client who needs a bed cradle, which action should the nurse include?
- A. Teach the client to call for help before getting out of bed.
- B. Keep both the upper and lower side rails in a raised position.
- C. Keep the bed in the lowest position while changing the sheets.
- D. Drape the top sheet and covers loosely over the bed cradle.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
- A. Performing ROM exercises during bathing.
- B. Changing the patient's position every two hours.
- C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
- D. Placing the patient in the prone position for one hour three times a day.
Correct Answer: C
Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.
At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
- B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked.
- C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.
Correct Answer: C
Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct Answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.