Question

After returning to the room following physical therapy, the nurse observes that a client has blue-tinged lips. Which vital sign should the nurse obtain first?

Answer 1

Correct Answers:

Respiratory rate.

Rationale :

✳️ Blue-tinged lips indicate cyanosis, which can signal inadequate oxygenation and requires immediate assessment of the client's respiratory status.

✳️ Following the ABC priority framework, breathing takes precedence because impaired ventilation can rapidly become life-threatening.

✳️ The nurse should assess the respiratory rate, depth, pattern, effort, and breath sounds while also evaluating oxygen saturation as soon as possible.

✳️ Recent physical activity may temporarily increase oxygen demand, but persistent cyanosis suggests that the client may not be meeting that increased demand adequately.

✳️ Therefore, obtaining the respiratory rate first provides the most immediate information about a potentially compromised breathing status.

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Answer 2

Correct Answers:

Verify placement of pulse oximeter.

Rationale :

🖊️ An oxygen saturation of 89% is abnormally low, but the nurse should first verify that the pulse oximeter is positioned correctly and producing an accurate reading.

🖊️ Poor probe placement, movement, cold extremities, nail products, or decreased peripheral perfusion can produce falsely low SpO₂ measurements.

🖊️ Confirming the measurement prevents unnecessary changes in oxygen therapy based on inaccurate data.

🖊️ If the saturation remains low after verification, the nurse should immediately assess the client's respiratory status and then titrate oxygen according to the prescription or clinical protocol.

🖊️ Therefore, verifying pulse-oximeter placement is the appropriate first action before escalating oxygen delivery in this otherwise limited scenario.

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Answer 3

Correct Answers:

When the nurse noted that the client was wheezing
After the administration of albuterol
After the client mobilized with physical therapy
On admission to the rehabilitation unit

Rationale :

When the nurse noted that the client was wheezing

✳️ New wheezing represents a change in respiratory status and warrants immediate reassessment of vital signs, especially respiratory rate, heart rate, blood pressure, and oxygenation.

✳️ The client has a history of asthma, so wheezing may indicate bronchospasm and worsening airflow obstruction requiring prompt evaluation.

✳️ Vital signs help determine whether the respiratory problem is associated with tachypnea, tachycardia, hypoxemia, or hemodynamic instability.

✳️ Because this client recently survived septic shock and has just transferred from the ICU, any acute change in condition should be evaluated carefully rather than waiting for the routine 4-hour measurement.

✳️ Therefore, the nurse should have obtained vital signs when wheezing was first observed to establish the severity of the change and guide intervention.

After the administration of albuterol

✳️ The nurse should reassess the client after administering albuterol to determine whether the medication relieved bronchospasm and improved the respiratory status.

✳️ Post-treatment vital signs are also important because albuterol can produce cardiovascular effects such as tachycardia, palpitations, and changes in blood pressure.

✳️ Comparing pre- and post-treatment respiratory rate and heart rate helps determine both the therapeutic response and potential adverse effects of the medication.

✳️ The nurse should additionally reassess breath sounds, work of breathing, wheezing, and oxygen saturation after the nebulized treatment.

✳️ Therefore, obtaining vital signs after albuterol is appropriate because medication administration should be followed by evaluation of effectiveness and safety.

After the client mobilized with physical therapy

✳️ This was the client's first time out of bed after several weeks in the ICU, making activity tolerance an important concern.

✳️ Walking with crutches after prolonged critical illness can cause changes in heart rate, respiratory rate, blood pressure, and oxygen requirements.

✳️ The client also has a recent history of septic shock and a traumatic amputation, so deconditioning and orthostatic or exertional intolerance may be present.

✳️ Assessing vital signs after physical therapy allows the nurse to determine how well the client tolerated the activity and whether the rehabilitation plan should be advanced safely.

✳️ Therefore, vital signs should have been checked after mobilization with physical therapy, particularly because this was the client's first activity after prolonged immobility.

On admission to the rehabilitation unit

✳️ A complete set of baseline vital signs should be obtained when a client is admitted or transferred to a new nursing unit.

✳️ Baseline measurements allow the rehabilitation nurse to compare future findings with the client's condition at the time of transfer.

✳️ This is particularly important because the client recently experienced septic shock and a prolonged ICU stay, which increase the risk for residual instability and complications.

✳️ The provider also specifically prescribed vital signs every 4 hours, so the schedule should begin with an admission assessment.

✳️ Therefore, the nurse should have measured the client's vital signs upon admission to the rehabilitation unit to establish a safe clinical baseline.

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Answer 4

Correct Answers:

While touching the client’s forearm, asks, “Would you like to talk about it?”

Rationale :

✳️ This response uses therapeutic communication by acknowledging the client's emotional distress and offering an opportunity to express feelings.

✳️ An open-ended invitation such as “Would you like to talk about it?” allows the client to decide whether to discuss the issue rather than forcing conversation.

✳️ Appropriate supportive touch can communicate presence, empathy, and concern when acceptable to the client and consistent with cultural preferences.

✳️ Remaining available also demonstrates that the nurse considers the client's emotional needs an important part of the assessment rather than an inconvenience.

✳️ Therefore, this response is best because it promotes emotional expression, autonomy, and a therapeutic nurse-client relationship.

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Answer 5

Correct Answers:

Describes having a “body-wracking dry cough” of 6 weeks’ duration.

Rationale :

🖊️ Nursing documentation should accurately reflect the client's subjective report, particularly when describing symptoms that the nurse has not independently observed.

🖊️ Using quotation marks around “body-wracking dry cough” preserves the client's own description without adding interpretation.

🖊️ Including the 6-week duration provides clinically important information about the persistence of the symptom.

🖊️ Objective, specific documentation allows subsequent healthcare providers to assess the client's concern without introducing assumptions or diagnostic conclusions.

🖊️ Therefore, documenting the client's exact description and duration is the most accurate and defensible entry.

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Answer 6

Correct Answers:

“What brought you to the clinic?”

Rationale :

👉 This is an open-ended question that allows the client to describe the reason for seeking care in their own words.

👉 Open-ended questions encourage clients to provide information about symptoms, concerns, expectations, and other relevant issues without restricting the response.

👉 The nurse can then use more focused questions to clarify specific details after understanding the client's primary concern.

👉 This approach supports a comprehensive assessment and decreases the likelihood that an important concern will be overlooked.

👉 Therefore, “What brought you to the clinic?” is the best initial question for eliciting the greatest amount of information.

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Answer 7

Correct Answers:

Coarse crackles.

Rationale :

✍️ Pneumonia causes inflammation and accumulation of fluid or exudate within the alveoli and small airways.

✍️ As air moves through fluid-containing airways during inspiration, discontinuous popping or bubbling sounds known as crackles can be heard.

✍️ Coarse crackles are especially associated with increased secretions and consolidation in lower respiratory tract disorders such as pneumonia.

✍️ The abnormal sounds would be expected to be most prominent over the right lower lobe, where the infection is located.

✍️ Therefore, coarse crackles are the most likely auscultatory finding in a client with right lower lobe pneumonia.

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Answer 8

Correct Answers:

Begin with questions that are less sensitive in nature.

Rationale :

♦️ Sensitive topics such as alcohol and substance use are best addressed after the nurse establishes rapport, trust, and psychological safety.

♦️ Beginning with less threatening questions helps the client become comfortable with the interview process before discussing potentially stigmatizing behaviors.

♦️ The nurse should use a nonjudgmental, matter-of-fact tone to reduce embarrassment and encourage truthful disclosure.

♦️ As trust develops, questions can gradually become more specific about frequency, quantity, consequences, and patterns of substance use.

♦️ Therefore, beginning with less sensitive questions facilitates a more open and accurate health history.

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Answer 9

Correct Answers:

Obtain a baseline set of vital signs.

Rationale :

🔅 Obtaining routine temperature, pulse, respirations, and blood pressure is within the usual scope of an appropriately trained unlicensed assistive personnel.

🔅 The UAP can collect and report objective data, while the registered nurse remains responsible for interpreting findings and completing the nursing assessment.

🔅 Because this client has depression and unexplained fractures, specialized assessments involving safety, abuse, and suicide risk require professional nursing judgment.

🔅 Delegating routine data collection allows the nurse to concentrate on complex assessments that cannot safely be transferred to unlicensed personnel.

🔅 Therefore, obtaining baseline vital signs is the most appropriate task to delegate to the UAP.

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Answer 10

Correct Answers:

Migrant workers who plant and harvest field crops.

Rationale :

🖍️ Migrant agricultural workers often experience multiple health risks related to occupational exposures, poverty, unstable housing, transportation barriers, and limited access to healthcare.

🖍️ Their work can involve pesticide exposure, heat illness, musculoskeletal injury, dehydration, and long hours of strenuous physical activity.

🖍️ Frequent relocation can interfere with continuity of care, preventive screening, immunizations, and management of chronic conditions.

🖍️ Language, insurance, immigration concerns, and limited financial resources can further restrict access to traditional healthcare services.

🖍️ Therefore, migrant agricultural workers represent a particularly vulnerable aggregate with a high need for accessible local public health services.

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QLexNursing

1 :
After returning to the room following physical therapy, the nurse observes that a client has blue-tinged lips. Which vital sign should the nurse obtain first?

2 :
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

3 :
Patient data.

Answer Options

4 :
The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

6 :
A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

7 :
A client is admitted with a diagnosis of right lower lobe pneumonia. Which breath sound is the nurse most likely to auscultate over the right lower lobe?

8 :
Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

9 :
The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

10 :
The public health nurse is working in an agriculture-based community near the United States-Mexico border. Which aggregate should the nurse identify as having the highest need for local public health services?

QLexNursing

1 : After returning to the room following physical therapy, the nurse observes that a client has blue-tinged lips. Which vital sign should the nurse obtain first?

2 : The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

3 : Patient data.

Answer Options

4 : The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

6 : A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

7 : A client is admitted with a diagnosis of right lower lobe pneumonia. Which breath sound is the nurse most likely to auscultate over the right lower lobe?

8 : Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

9 : The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

10 : The public health nurse is working in an agriculture-based community near the United States-Mexico border. Which aggregate should the nurse identify as having the highest need for local public health services?

1 :
After returning to the room following physical therapy, the nurse observes that a client has blue-tinged lips. Which vital sign should the nurse obtain first?

2 :
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

3 :
Patient data.

4 :
The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

6 :
A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

7 :
A client is admitted with a diagnosis of right lower lobe pneumonia. Which breath sound is the nurse most likely to auscultate over the right lower lobe?

8 :
Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

9 :
The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

10 :
The public health nurse is working in an agriculture-based community near the United States-Mexico border. Which aggregate should the nurse identify as having the highest need for local public health services?