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When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
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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.
The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
- A. Increase the liter flow of oxygen.
- B. Encourage the client to take deep breaths.
- C. Remove the mask to deflate the bag.
- D. Document the assessment data.
Correct Answer: A
Rationale: Increasing flow ensures oxygen delivery.
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.
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.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.