Nokea
The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Securely place the prongs of the cannula in the nostrils.
- C. Place the pulse oximeter on the client's earlobe.
- D. Document the second reading in the client's record.
Correct Answer: B
Rationale: Proper cannula placement ensures oxygen delivery.
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When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.
A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?
- A. Offer to contact the family's spiritual counselor to meet with the client and spouse.
- B. Discuss comfort measures with the client and family that will be available during withdrawal.
- C. Inform the healthcare provider of the client's desire to have life support withdrawn.
- D. Explain the actions that the healthcare team will follow for the removal of life support.
Correct Answer: C
Rationale: Notifying provider respects client autonomy.
A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
- A. Confer with the physical therapist for correct crutch size.
- B. Ask the client to sit down while the crutch length is adjusted.
- C. Assess the client for signs of diminished circulation in the hands.
- D. Proceed with teaching the client how to walk with the crutches.
Correct Answer: D
Rationale: Three-finger gap indicates proper fit.
A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
- A. Skin turgor.
- B. Weight.
- C. Blood pressure.
- D. Lung sounds.
Correct Answer: B
Rationale: Daily weight accurately tracks fluid balance.