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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.
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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
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.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
- A. Increase the liter flow of oxygen.
- B. Encourage the client to take deep breaths.
- C. Remove the mask to deflate the bag.
- D. Document the assessment data.
Correct Answer: A
Rationale: Increasing flow ensures oxygen delivery.
While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?
- A. Obtain the specimen from the client's current bowel movement.
- B. Contact the healthcare provider before obtaining the specimen.
- C. Wait to obtain the specimen until observable blood is present.
- D. Withhold specimen collection until tarry black stool is observed.
Correct Answer: A
Rationale: Normal stool is suitable for occult blood testing.