A nurse is assisting with the care of four clients. Which of the following clients is the priority
for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - ANSWER - A client who has chest
tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should
determine that the priority finding is the client's oxygen saturation level, which is below the
expected reference range of 95% to 100%. Therefore, the nurse should attend to this client
first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3.
Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - ANSWER Nonresponsive Commands
1
,A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose
state. The GCS is a standardized tool that allows for the evaluation of a client's level of
consciousness. The test is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low
score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a
closed chest drainage system connected to low suction. For which of the following findings
should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - ANSWER - Persistent bubbling in the
water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the
drainage system. The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
preforming ADL's. Which of the following instructions should the nurse include in the
teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - ANSWER Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to reduce
frustration and increase independence and self-esteem.
2
, A nurse is collecting data from a client and auscultates intermittent high-pitched sounds
during inspiration over the lower base of the lungs. The nurse should identify this finding as
which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - ANSWER - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions.
Fine crackles are intermittent, high-pitched sounds heard more often during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of the
following
manifestations should the nurse identify as an indication that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - ANSWER - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - ANSWER A client who has
diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority action is to attend to a client who has diabetes mellitus and is diaphoretic.
Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function.
3
for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - ANSWER - A client who has chest
tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should
determine that the priority finding is the client's oxygen saturation level, which is below the
expected reference range of 95% to 100%. Therefore, the nurse should attend to this client
first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3.
Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - ANSWER Nonresponsive Commands
1
,A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose
state. The GCS is a standardized tool that allows for the evaluation of a client's level of
consciousness. The test is divided into three sections that evaluate eye opening, motor
response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low
score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a
closed chest drainage system connected to low suction. For which of the following findings
should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - ANSWER - Persistent bubbling in the
water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the
drainage system. The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
preforming ADL's. Which of the following instructions should the nurse include in the
teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - ANSWER Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to reduce
frustration and increase independence and self-esteem.
2
, A nurse is collecting data from a client and auscultates intermittent high-pitched sounds
during inspiration over the lower base of the lungs. The nurse should identify this finding as
which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - ANSWER - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions.
Fine crackles are intermittent, high-pitched sounds heard more often during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of the
following
manifestations should the nurse identify as an indication that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - ANSWER - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - ANSWER A client who has
diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should determine
that the priority action is to attend to a client who has diabetes mellitus and is diaphoretic.
Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function.
3
