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Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.
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Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
Select the 5 findings that require immediate follow-up
- A. Stool results
- B. Hemoglobin and Hematocrit
- C. Respiratory rate
- D. Heart rate
- E. Current medications
- F. Temperature
- G. WIC count
Correct Answer: A,B,D,E,H
Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (B) levels indicate blood health. Heart rate (D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (C) and temperature (F) are important but not as urgent.
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr
- B. A client who received a pain medication 30 min ago for postoperative pain
- C. A client who was just given a glass of orange juice far a low blood glucose level
- D. A client who has 100 mL of fluid remaining in his IV bag
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.