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, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.
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A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?
- A. Plan to assign the client a different nurse each shift
- B. Limit the number of interdisciplinary team members involved in managing the client's care
- C. Request that the client complete a satisfaction survey at discharge
- D. Start discharge planning on the day of admission
Correct Answer: D
Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.
A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention?
- A. Providing cholesterol screening
- B. Teaching about a healthy diet
- C. Providing information about antihypertensive medications
- D. Developing a list of cardiac rehabilitation programs
Correct Answer: B
Rationale: Teaching about a healthy diet is considered a primary prevention activity. Primary prevention aims to prevent the onset of a disease or health problem. Educating individuals on healthy lifestyle choices, such as diet modification, falls under primary prevention. Providing cholesterol screening (choice A) is a secondary prevention measure aimed at early detection. Offering information about antihypertensive medications (choice C) falls under secondary prevention, focusing on controlling risk factors. Developing a list of cardiac rehabilitation programs (choice D) is part of tertiary prevention, focusing on rehabilitation and improving outcomes post-disease onset.
The healthcare provider is assessing a client diagnosed with rheumatoid arthritis. Which assessment finding would be most concerning?
- A. Morning stiffness
- B. Joint deformities
- C. Weight loss
- D. Fever
Correct Answer: D
Rationale: Fever in a client with rheumatoid arthritis can indicate an underlying infection or a more serious systemic involvement, such as vasculitis or inflammation of internal organs. These conditions can lead to serious complications and require immediate medical attention. Joint deformities and morning stiffness are common manifestations of rheumatoid arthritis itself and may not be indicative of an acute issue. Weight loss can be seen in chronic inflammatory conditions like rheumatoid arthritis but is not as concerning as fever, which suggests an acute process requiring prompt evaluation and intervention.
A client with a history of severe anxiety is scheduled for surgery. Which preoperative medication is the most appropriate for the LPN/LVN to administer to this client?
- A. Lorazepam (Ativan)
- B. Morphine sulfate
- C. Meperidine (Demerol)
- D. Promethazine (Phenergan)
Correct Answer: A
Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.
A healthcare professional is preparing to admit a client suspected of having pulmonary tuberculosis. Which of the following actions should the healthcare professional plan to perform first?
- A. Implement airborne precautions.
- B. Obtain a sputum culture.
- C. Administer antituberculosis medications.
- D. Recommend a screening test for close contacts.
Correct Answer: A
Rationale: The initial priority when admitting a client suspected of having pulmonary tuberculosis is to implement airborne precautions to prevent the spread of the disease. Airborne precautions include wearing a mask and placing the client in a negative pressure room. Obtaining a sputum culture is essential for confirming the diagnosis, but ensuring infection control measures come first to protect others. Administering antituberculosis medications is important but should be initiated after implementing necessary precautions. Recommending a screening test for close contacts is relevant but is a secondary concern compared to immediate infection control measures.