Question

A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Use the palpatory method to determine blood pressure.

Rationale :

🔷 When auscultation is difficult, the palpatory method is a reliable technique to estimate systolic blood pressure by palpating the radial pulse while inflating the cuff.

🔷 This helps identify the level at which the pulse disappears and reappears, offering a reference point for accurate auscultation.

🔷 It is especially helpful in noisy environments or in clients with faint Korotkoff sounds.

🔷 This method improves accuracy and prevents underestimation of systolic pressure.

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Answer 2

Correct Answers:

Hypertension.

Rationale :

🟠 Hypertension is a contraindication for combination oral contraceptive use due to the increased risk of cardiovascular events, including stroke and thromboembolism.

🟠 Estrogen-containing contraceptives elevate blood pressure and potentiate vascular complications.

🟠 Safe alternatives like progestin-only methods may be considered in hypertensive individuals.

🟠 Nurses must educate clients on risks and assess for comorbidities before initiating hormonal therapy.

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Answer 3

Correct Answers:

Administer analgesics on a scheduled basis for the first 24 hr.

Rationale :

💠 Scheduled analgesia ensures consistent pain relief, especially during the immediate postoperative period following an appendectomy.

💠 Effective pain control supports early mobilization, deep breathing, and reduces the risk of complications such as atelectasis.

💠 Waiting for the child to request pain medication may delay relief and increase anxiety.

💠 Proactive pain management also supports a positive surgical recovery experience.

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Answer 4

Correct Answers:

Hematuria

Rationale :

🟢 Hematuria, or blood in the urine, is a classic manifestation of acute glomerulonephritis due to glomerular inflammation.

🟢 The urine may appear tea-colored or smoky, reflecting red blood cell leakage.

🟢 Other signs include edema, proteinuria, and hypertension, often following a recent streptococcal infection.

🟢 Nurses should monitor urine output, renal labs, and blood pressure closely.

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Answer 5

Correct Answers:

Digoxin 0.25 mg PO daily

Rationale :

🔶 A complete prescription must include the medication name, dose, route, and frequency—all of which are present in this order.

🔶 Clarity in prescriptions ensures safe administration and prevents medication errors.

🔶 Incomplete prescriptions lacking any of these components (like route or dose) require clarification.

🔶 Nurses must verify and advocate for safe, clear orders at all times.

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Answer 6

Correct Answers:

"You don't have to go through with the treatment."

Rationale :

🔷 Clients have the right to withdraw consent at any time, even after previously agreeing to a procedure like ECT.

🔷 Respecting the client's decision reinforces the ethical principle of autonomy.

🔷 This response is non-coercive, therapeutic, and acknowledges the client's control over their healthcare.

🔷 Nurses must remain advocates for informed, voluntary consent at all stages of care.

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Answer 7

Correct Answers:

Sit at or below the client's eye level during feedings.

Rationale :

🟠 Sitting at or below eye level allows the nurse to closely monitor for signs of dysphagia, such as coughing or difficulty swallowing.

🟠 This position creates a calm, supportive feeding environment and encourages safe swallowing mechanics.

🟠 It also facilitates eye contact and client engagement, improving comfort and reducing anxiety.

🟠 Clients with dysphagia are at high risk for aspiration pneumonia, making proper feeding techniques essential.

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Answer 8

Correct Answers:

"Advance directives can be signed without legal representation."

Rationale :

💠 In most jurisdictions, advance directives do not require a lawyer and can be completed using standard forms provided by healthcare institutions.

💠 This reassurance can remove barriers and encourage clients to express their treatment preferences in writing.

💠 Nurses should educate clients that notarization or legal review is optional, not mandatory.

💠 Promoting advance directives enhances client autonomy and end-of-life planning.

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Answer 9

Correct Answers:

Partial separation of the upper part of the incisional line

Rationale :

🟡 Partial separation of a surgical incision may indicate wound dehiscence, a serious complication requiring immediate provider notification.

🟡 Dehiscence can progress to evisceration if untreated, posing risk for infection and delayed healing.

🟡 Mild swelling, pinkness, and crusting are expected post-op findings, but any separation must be promptly reported.

🟡 Nurses must assess incision sites at every shift and with each dressing change.

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Answer 10

Correct Answers:

The client is oriented times three.

Rationale :

🔵 A Glasgow Coma Scale (GCS) score of 15 reflects a client who is fully alert and oriented to person, place, and time.

🔵 This includes spontaneous eye opening, appropriate verbal responses, and the ability to obey commands.

🔵 Lower GCS scores are associated with altered mental status, such as eye opening to sound or pain withdrawal.

🔵 GCS is a standardized tool used to assess neurological function following trauma or injury.

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QLexNursing

1 :
A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

2 :
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?

3 :
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 :
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?

6 :
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

7 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

8 :
A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

9 :
A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

10 :
A nurse in an emergency department is caring for a client following a motor vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?

QLexNursing

1 : A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

2 : A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?

3 : A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

4 : A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 : A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?

6 : A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

7 : A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

8 : A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

9 : A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

10 : A nurse in an emergency department is caring for a client following a motor vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?

1 :
A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?

2 :
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?

3 :
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 :
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?

6 :
A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?

7 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

8 :
A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?

9 :
A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

10 :
A nurse in an emergency department is caring for a client following a motor vehicle crash. The client's Glasgow coma scale rating is 15. Which of the following findings should the nurse expect?