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Why should a nurse use affective touching cautiously?
- A. It may lead to misunderstandings or discomfort.
- B. It involves the contact required for nursing procedures.
- C. It is used therapeutically when a client is lonesome.
- D. It involves the touch used for sensory-deprived clients.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What is the correct sequence of examination techniques that should be used when assessing the patient’s abdomen?
- A. Inspection, palpation, auscultation, percussion
- B. Palpation, percussion, auscultation, inspection
- C. Auscultation, inspection, percussion, palpation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy, and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the client's oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.
Mr. Jones wants to lose 2 lb/wk. How many calories must he reduce daily?
- A. 300
- B. 500
- C. 1000
- D. 1200
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What should the nurse closely monitor for in a client who has undergone surgery for otosclerosis?
- A. Hypotension
- B. Nausea and vomiting
- C. Decreased urine output
- D. Abnormal facial nerve function
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which intervention can help a visually impaired client achieve independence?
- A. Keep personal care items in a different location each day
- B. Ask the client’s preference for where to store hygiene articles and other objects needed for self-care
- C. At mealtimes, ask the client to feel where food is on the plate
- D. Place meal tray on overbed tray and leave the room
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.