Question

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Raise the head of the bed.

Rationale :

🔘 Raising the head of the bed improves ventilation and oxygenation by promoting lung expansion and reducing pressure on the diaphragm.

🔘 It helps increase functional residual capacity, allowing better oxygen exchange in patients with pneumonia.

🔘 Although encouraging coughing and deep breathing is important, optimizing position comes first to support oxygenation.

🔘Humidification therapy is supportive but does not immediately improve oxygen saturation.

🔘 Increasing oral fluids helps thin secretions but is a secondary intervention.

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Answer 2

Correct Answers:

Presence of pain

Rationale :

◼️ Pain is a common cause of sleep disturbances in hospitalized patients, often preventing deep, restorative sleep.

◼️ Moderate fatigue usually promotes sleep, rather than interfering with it.

◼️ Being able to talk about daily events generally supports relaxation and better sleep.

◼️ The absence of unfamiliar stimuli actually supports better sleep quality.

◼️ Managing pain effectively is crucial to improving sleep patterns in acute care.

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Answer 3

Correct Answers:

Remove blankets and offer fluids

Rationale :

♦️ Removing blankets helps to reduce body temperature by allowing heat loss through radiation and convection.

♦️Offering fluids helps prevent dehydration and supports cooling through perspiration.

♦️ Increasing activity is contraindicated, as it can raise metabolic heat production.

♦️Applying ice bags directly can cause vasoconstriction and discomfort, which is generally not recommended for fever management.

♦️ Decreasing intake would worsen dehydration and is inappropriate.

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Answer 4

Correct Answers:

"It sounds like you're having a difficult time."

Rationale :

✓ This response uses therapeutic communication, acknowledging the client's feelings without judgment.

✓ It encourages further expression and builds rapport, which can help reduce anxiety.

✓Asking "why" questions can make the client feel defensive or misunderstood.

✓ Suggesting to talk to the provider prematurely may discourage open discussion.

✓ Minimizing the client’s feelings with general statements may invalidate their experience.

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Answer 5

Correct Answers:

Positioning the client's arm above heart level

Rationale :

● Positioning the arm above heart level decreases hydrostatic pressure, leading to falsely low blood pressure readings.

● Wrapping the cuff too loosely usually causes falsely high readings.

● Measuring blood pressure after meals does not typically lower readings and may slightly increase it.

● Deflating the cuff too slowly can distort the reading but generally causes falsely high systolic and low diastolic readings.

● Proper arm positioning at heart level is essential for accurate blood pressure measurement.

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Answer 6

Correct Answers:

Count the apical pulsations for a full minute

Rationale :

♦️ The nurse should count the apical pulse for a full minute to obtain an accurate assessment, especially in clients on cardiovascular medications that may affect heart rate and rhythm.

♦️ Using the diaphragm of the stethoscope is appropriate for heart sounds, but the focus is on counting duration for accuracy, not the type of stethoscope part.

♦️ Pressing the stethoscope too firmly can distort sounds and cause discomfort.

♦️ A Doppler device is used when pulse sounds are difficult to hear but is not the first choice.

♦️ Accurate pulse assessment helps in monitoring for adverse medication effects such as bradycardia.

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Answer 7

Correct Answers:

Have two glasses of wine every night before bedtime.

Rationale :

✓ Alcohol consumption before bed disrupts sleep patterns by interfering with REM sleep and causing early awakenings.

✓ Although it may initially induce sleepiness, it ultimately leads to poor sleep quality and insomnia.

✓ Exercising regularly and maintaining a consistent bedtime promotes good sleep hygiene.

✓ Getting out of bed when unable to sleep helps prevent the development of negative associations with the bed.

✓ Addressing lifestyle factors like alcohol intake is essential in managing insomnia.

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Answer 8

Correct Answers:

"As long as I change my gloves between clients, it is not necessary to wash my hands."

Rationale :

● Gloves can have microscopic tears and may become contaminated during use, so hand hygiene is necessary even when gloves are changed.

● Washing hands when visibly dirty and using alcohol-based hand sanitizers are critical infection control practices.

● Artificial nails harbor pathogens and should be avoided in clinical settings.

● Proper hand hygiene is the most effective way to prevent healthcare-associated infections.

● This statement indicates a misunderstanding and requires further teaching.

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Answer 9

Correct Answers:

Gloves

Rationale :

⬛ Gloves are the most contaminated piece of personal protective equipment and should be removed first to prevent contamination of other PPE or the environment.

⬛ The mask is typically removed last to maintain protection until all other contaminated PPE is off.

⬛ Removing PPE in the correct order reduces the risk of self-contamination.

⬛ Proper PPE removal technique is essential for infection control and nurse safety.

⬛ Education and adherence to protocol are key to preventing spread of infection.

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Answer 10

Correct Answers:

Edema

Rationale :

◼️ Edema (swelling) around a wound is a common sign of inflammation and possible infection due to increased fluid and immune response.

◼️ Petechiae and urticaria are not typical wound infection signs but may relate to other conditions like bleeding disorders or allergies.

◼️ Crusting over granulated tissue usually indicates healing, not infection.

◼️ Recognizing infection signs early enables timely treatment to prevent complications.

◼️ Monitoring wound condition is an essential part of nursing care.

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QLexNursing

1 :
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

2 :
A client complains of an inability to sleep through the night since admission three days ago. Which of the following factors is most likely to negatively affect the patient's sleep patterns?

3 :
A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

4 :
A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 :
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

6 :
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

7 :
A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

8 :
A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

9 :
A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

10 :
A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

QLexNursing

1 : A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

2 : A client complains of an inability to sleep through the night since admission three days ago. Which of the following factors is most likely to negatively affect the patient's sleep patterns?

3 : A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

4 : A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 : When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

6 : A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

7 : A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

8 : A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

9 : A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

10 : A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

1 :
A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

2 :
A client complains of an inability to sleep through the night since admission three days ago. Which of the following factors is most likely to negatively affect the patient's sleep patterns?

3 :
A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:

4 :
A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 :
When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

6 :
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

7 :
A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

8 :
A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

9 :
A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

10 :
A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?