Nokea
Which of the following statements should the nurse make?
- A. Do you need a prescription for an antianxiety medication?
- B. Do you need information on hospice care?
- C. Would you like to talk to a counselor about advance directives?
- D. Would you like to speak to a spiritual advisor?
Correct Answer: D
Rationale: Spiritual support can help address emotional and existential concerns in terminally ill clients.
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Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: D
Rationale: The correct answer is D: Hematoma over the insertion site. This finding indicates potential internal bleeding, which can lead to complications. Notify the provider to assess and manage promptly. A: Discomfort at insertion site is common post-procedure and can be managed with appropriate interventions. B: Heart rate of 90/min is within normal range and does not require immediate provider notification. C: Bounding pulses in the affected extremity may indicate adequate perfusion and is not a concerning finding.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
Which of the following anterior chest wall locations should the nurse auscultate?(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Correct Answer:
Rationale: Correct Answer: D (Second intercostal space, right sternal border)
Rationale: The nurse should auscultate at the second intercostal space, right sternal border to listen to the aortic valve. This location corresponds to the area where the aortic valve can be best heard. The aortic valve is located in the second intercostal space, right sternal border, so auscultating at this spot allows for accurate assessment of the heart sounds in this area. It is essential to auscultate at this specific location to detect any abnormalities or abnormalities in the aortic valve.
Summary of other choices:
- A, B, C, E, F, G: These locations do not correspond to the specific area where the aortic valve is best heard. Auscultating at these locations may not provide clear or accurate heart sounds related to the aortic valve.
Which of the following instructions should the nurse include in the teaching?
- A. Place tongue on the mouthpiece of the meter
- B. Maintain a semi-Fowler's position during testing
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D because blowing into the meter as hard and quickly as possible ensures accurate lung function test results. This instruction ensures a consistent and forceful flow of air, which is crucial for reliable readings. Option A is incorrect because the tongue should not be placed on the mouthpiece, as this can affect the accuracy of the test. Option B is incorrect as maintaining a semi-Fowler's position is not necessary for this test. Option C is incorrect because recording the average of the readings is not a step in the actual testing process.