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 suggests respiratory issues, needing immediate assessment.
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The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
- A. Apply a lubricating lotion to the skin.
- B. Pad all bony prominences.
- C. Encourage a high protein diet.
- D. Bathe with a mild soap daily.
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.
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. Impaired bed mobility.
- B. Fluid volume deficit.
- C. Bowel incontinence.
- D. Caregiver role strain.
Correct Answer: B
Rationale: Diarrhea risks dehydration, requiring urgent fluid management.
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.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
- A. Hypothyroidism.
- B. Hypertension.
- C. Peptic ulcer disease.
- D. Fibromyalgia.
Correct Answer: B
Rationale: Sleep apnea increases hypertension risk due to oxygen desaturation.