Nokea
While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?
- A. Apply a pulse oximeter
- B. Measure blood pressure
- C. Notify the charge nurse
- D. Observe pressure areas
Correct Answer: C
Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.
You may also like to solve these questions
While performing an inspection of a client's fingernails, the PN observes a suspected abnormality of the nail's shape and character. Which finding should the PN document?
- A. Clubbed nails
- B. Splinter hemorrhages
- C. Longitudinal ridges
- D. Koilonychia or spoon nails
Correct Answer: A
Rationale: The correct answer is A: Clubbed nails. Clubbed nails are a significant finding often associated with chronic hypoxia or lung disease. The presence of clubbed nails should be documented for further evaluation. Splinter hemorrhages (Choice B) are tiny areas of bleeding under the nails and are associated with conditions like endocarditis. Longitudinal ridges (Choice C) are common and often a normal finding in older adults. Koilonychia or spoon nails (Choice D) refer to nails that are concave or scooped out, often seen in conditions like iron deficiency anemia or hemochromatosis. These conditions are not typically associated with chronic hypoxia or lung disease, making them less likely findings in this situation.
You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?
- A. 10
- B. 8
- C. 7
- D. 9
Correct Answer: D
Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.
A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?
- A. Encourage deep breathing and the use of the incentive spirometer.
- B. Administer antipyretic medication as prescribed.
- C. Notify the healthcare provider immediately.
- D. Increase the client's fluid intake.
Correct Answer: A
Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client's fluid intake (option D) is important for overall recovery but is not the priority in this scenario.
Which assessment finding would most likely indicate a complication of enteral tube feeding?
- A. Abdominal distension
- B. Weight gain
- C. Decreased bowel sounds
- D. Diarrhea
Correct Answer: A
Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.
The nurse is preparing to provide wound care for a client. Which step should be done first?
- A. Don procedural gloves
- B. Remove the dressing
- C. Apply prescribed medications to the wound
- D. Don a pair of sterile gloves
Correct Answer: A
Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.