Nokea
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis indicates oxygenation issues, requiring respiratory assessment.
You may also like to solve these questions
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations engage active problem-solving.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Keep the medication and see if the client will want to take it later.
- B. Credit the medication back and put it in the client's medication box.
- C. Explain that since the medication is a controlled substance it must be taken.
- D. Have another nurse watch the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal ensures safety and compliance.
History and physical
The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Review H and P and nurse's note.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. Create a toilet training program;Place an indwelling catheter;Place an incontinence containment product under the client;Teach the client to use mobility aids;Provide skin care
- B. Urge incontinence;Reflex urinary incontinence;Overflow urinary incontinence;Functional incontinence
- C. Intake and output;Blood pressure;Postvoid residual volume;Skin integrity;Blood glucose
Correct Answer:
Rationale: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.
The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
- A. Warn the colleague that their actions are unprofessional.
- B. Discuss the action at the next staff meeting.
- C. Communicate the observation to the charge nurse.
- D. File a detailed incident report with the specific facility.
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.