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The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Collect the blood sample.
- B. Select another finger.
- C. Apply pressure to the site.
- D. Assess radial pulse volume.
Correct Answer: B
Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.
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A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Muscle atrophy.
- B. Low grade fever.
- C. Joint pain.
- D. Hematuria.
Correct Answer: D
Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
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 to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Orient the client to the environment
- B. Call for an ophthalmological exam
- C. Provide an eye patch
- D. Avoid activities that will increase intraocular pressure
- E. Strabismus
- F. Glaucoma
Correct Answer: D
Rationale: The client is most likely experiencing diabetic retinopathy, a complication of poorly controlled type 1 diabetes. Calling for an ophthalmological exam and orienting the client to the environment address the condition, while monitoring blood glucose and visual acuity assess progress.
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns of dietary intake.
- B. Activity level of bowel sounds.
- C. Level and amount of physical activity.
- D. Color and consistency of feces.
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
History and Physical Nurses' Notes
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
Initial Assessment
Temperature 98.9° F (37.1° C)
Heart rate 112 beats/minute
Respirations 28 breaths/minute
Blood pressure 130/86 mm Hg
Oxygen saturation 88% on room air
Lung sounds reveal expiratory wheezes
Capillary refill time 2 seconds
Orders
Administer albuterol 2.5 mg/ipratropium bromide 0.5 mg in 3 mL solution via nebulizer four times a day and PRN.
Administer prednisone 60 mg PO
Administer oxygen to keep oxygen saturation greater than 94%, titrate as needed.
The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful.
- A. Decrease in heart rate from 112 to 105 beats per minute.
- B. Client able to speak in full sentences without pausing.
- C. Clear lung sounds.
- D. Reduction in respiratory rate to 16 breaths per minute.
- E. Client reports breathing is eased.
- F. Blood pressure within normal limits.
Correct Answer: A,B,C,D,E,F
Rationale: The assessment data showing decreased heart rate, ability to speak in full sentences, clear lung sounds, reduced respiratory rate, eased breathing, and stable blood pressure all indicate successful interventions for the asthma attack.
A client receives a prescription for 3 liters of lactated Ringer's IV to infuse over 24 hours. How many mL/hr should the nurse program the infusion pump?
- A. 125
Correct Answer: A
Rationale: To calculate: 3000 mL / 24 hr = 125 mL/hr. The nurse should program the infusion pump to deliver 125 mL/hr.