Nokea
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
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The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
- A. Call the health care provider
- B. Check vital signs
- C. Position in high Fowler's
- D. Administer oxygen
Correct Answer: D
Rationale: Administer oxygen. In a medical emergency, airway and breathing are prioritized. Oxygen administration addresses the immediate respiratory distress.
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A. bounding pulse
- B. rapid respirations
- C. oliguria
- D. neck veins are distended
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.
The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.