Nokea
The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. 2+ edema of fingers and hands.
- B. Capillary refill time is 2 seconds.
- C. Blood pressure is 142/88 mm Hg.
- D. Radial pulse volume is 3+.
Correct Answer: A
Rationale: Edema distorts oximeter readings.
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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?
- A. Administering the medication to a client behind a closed curtain.
- B. Informing a client that the medication being administered is a vitamin.
- C. Placing a client in restraints without having a healthcare provider’s order.
- D. Enlisting security personnel to assist with restraining the client.
Correct Answer: B
Rationale: Deception violates informed consent.
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL.' How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
Correct Answer: 1
Rationale: 30 mg ÷ (30 mg/15 mL) = 1 tablespoon.
The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
- A. Begin the collection the next day.
- B. Empty the sample into the 24-hour container.
- C. Observe the sample for sediment.
- D. Start collecting the specimen with the next void.
Correct Answer: D
Rationale: First void is discarded for accuracy.
The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
- A. Determine the client’s activity tolerance.
- B. Teach the client to shorten the stride to prevent falls.
- C. Initiate a fall risk protocol for the client.
- D. Record the client’s ability to perform ADLs safely.
Correct Answer: D
Rationale: Documentation reflects functional status.