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The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?
- A. Administer PRN oral pain medication.
- B. Ask the client what is causing the grimacing.
- C. Monitor the client’s nonverbal behavior.
- D. Review the pain medications prescribed.
Correct Answer: B
Rationale: Clarifying nonverbal cues ensures accuracy.
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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.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/25 mL'. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 5
Rationale: 200 mg ÷ (1000 mg/25 mL) = 5 mL.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,D,E,F,G
Rationale: Context-dependent; typically every 4 hours.
A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking about the client’s laboratory results. Which response is best for the nurse to provide?
- A. The healthcare provider will share this information with you.'
- B. I’m sorry, but your child’s medical information is none of your business.'
- C. I can give you those results as soon as I get them back from the laboratory.'
- D. I can only give medical information to your child because they are legally an adult.'
Correct Answer: D
Rationale: Emancipated minors have autonomy.