Nokea
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
- A. Blood pressure.
- B. Respiratory rate.
- C. Temperature.
- D. Pulse rate.
Correct Answer: B
Rationale: If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation. Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation. Therefore, the nurse should obtain the respiratory rate first.
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The nurse is caring for a patient one week post-surgery.Which finding should the nurse expect to see if the surgical incision is healing properly?
- A. Eschar and slough in the wound.
- B. Beety red granulation tissue.
- C. Erythema and serosanguineous drainage.
- D. A well-approximated incision.
Correct Answer: D
Rationale: A well-approximated incision means that the edges of the wound are close together and aligned properly, which is a sign that the surgical incision is healing properly.
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet.While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
- A. On the dorsal surfaces.
- B. Between the toes.
- C. Over the heels.
- D. Around the ankles.
Correct Answer: B
Rationale: While drying the client's feet, the nurse should emphasize the need to thoroughly dry between the toes. Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete's foot.
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL'. How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: A
Rationale: Since the prescription is for 30 mg of dextromethorphan and the bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL', the client should take 15 mL of the suspension per dose. Since there are 15 mL in 1 tablespoon, the client should take 1 tablespoon of the suspension per dose.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Basilar lung sounds that are diminished in the left lung.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Capillary refill of 2 seconds in the lower right foot.
- D. Active bowel sounds in the lower right quadrant.
Correct Answer: A
Rationale: Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome. In this case, the nurse should document the assessment that is not within normal limits, which is 'Basilar lung sounds that are diminished in the left lung.'