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The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to ask the client about sexual activity. Which approach is best for the nurse to use?
- A. Begin with queries that are less sensitive in nature.
- B. Ask queries in a vague, non-specific format.
- C. Get the most difficult queries over with first.
- D. Share personal values to put the client at ease.
Correct Answer: A
Rationale: Less sensitive queries build rapport.
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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.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- 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.
A nurse is reviewing error prevention techniques that would have helped to avoid a medication error. Which technique is most effective?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
Correct Answer: D
Rationale: Identifiers prevent misidentification.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- A. Record a palpable systolic pressure of 90 mm Hg.
- B. Release the manometer valve immediately.
- C. Document the absence of the radial pulse.
- D. Inflate the blood pressure cuff to 120 mm Hg.
Correct Answer: D
Rationale: Inflate above pulse disappearance for accuracy.
The client had a large, loose stool.
Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.
Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.
Place the client on contact precautions.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take, and two parameters to assess the client’s progress.
- A. Collect stool for culture, Start a high-fiber diet., Administer an oral steroid.,Make the client NPO
- B. Secretory diarrhea.Steatorrhea,Motility diarrhea,Osmotic diarrhea
- C. Heart rate, Serum potassium,Respiratory rate, Urine sodium
Correct Answer:
Rationale: Secretory diarrhea fits; stool culture and NPO address infection; heart rate and potassium monitor dehydration.