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, known as cyanosis, may indicate inadequate oxygenation following physical exertion.

👃The respiratory rate provides immediate information about the client’s breathing effort, depth, and response to activity.

🚨Using the airway-breathing-circulation priority framework, the nurse should assess breathing before obtaining cardiovascular or temperature measurements.

🏃The recent physical therapy activity may have increased oxygen demand and revealed respiratory compromise.

📌Core Message

Cyanosis after exertion requires immediate assessment of respiratory status, beginning with the respiratory rate.

Answer 2

Correct Answers:

Verify placement of pulse oximeter.

Rationale :

📟An oxygen saturation of 89% is abnormal, but the nurse should first confirm that the reading is accurate.

🔍Incorrect pulse oximeter placement, movement, poor circulation, nail products, or a loose probe can produce a falsely low measurement.

🧠The nurse should follow the principle of assessing and validating data before changing oxygen therapy.

💁‍♂️After confirming the reading, the nurse can reassess the client and adjust supplemental oxygen as clinically indicated.

📌Core Message

An unexpected low oxygen saturation should first be validated by checking the pulse oximeter placement and signal quality.

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 :

🏥Vital signs should be measured on admission to establish a baseline assessment when the client arrives on the rehabilitation unit.

🏃Vital signs should be reassessed after physical therapy and mobilization because activity may affect oxygen saturation, pulse, respirations, and blood pressure.

💁‍♂️The development of wheezing represents a change in respiratory condition that requires immediate assessment of vital signs.

💊Vital signs should also be obtained after albuterol administration to evaluate therapeutic effectiveness and identify adverse effects such as tachycardia.

📌Core Message

Vital signs are required on admission, after physical activity, with new wheezing, and following bronchodilator therapy to identify changes and treatment responses.

Answer 4

Correct Answers:

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

Rationale :

🤝The response demonstrates therapeutic communication by acknowledging the client’s emotional distress and offering support.

🗣️An open-ended question allows the client to decide whether to discuss the reason for crying.

💙Appropriate therapeutic touch may communicate empathy and presence when the client appears receptive.

👂The nurse remains available for active listening rather than assuming the cause of the client’s emotions or leaving immediately.

📌Core Message

Therapeutic communication involves offering emotional presence, using an open-ended invitation, and allowing the client to choose whether to talk.

Answer 5

Correct Answers:

Presents with a hacking nonproductive cough of 6 weeks’ duration.

Rationale :

📝Clinical documentation should use objective, specific, and professional terminology.

💁‍♂️A nonproductive cough accurately communicates that the client is coughing without producing sputum.

📅Recording the six-week duration provides essential information about the persistence and clinical significance of the symptom.

⚖️The documentation avoids diagnosing lung cancer or recording an unverified fear as though it were a confirmed condition.

📌Core Message

Accurate documentation records the character and duration of the cough using objective terminology without implying an unconfirmed diagnosis.

Answer 6

Correct Answers:

“What brought you to the clinic?”

Rationale :

💁‍♂️“What brought you to the clinic?” is an open-ended question that encourages the client to describe concerns in their own words.

🔎The response can reveal symptoms, expectations, postoperative complications, and emotional concerns that the nurse might not anticipate.

👩‍⚕️Beginning with a broad question supports a client-centered interview and prevents the nurse from directing the conversation prematurely.

📋After the client responds, the nurse can ask focused questions to clarify the surgical history, pain, and current symptoms.

📌Core Message

An open-ended opening question elicits the greatest amount of information and allows the client to direct the initial clinical history.

Answer 7

Correct Answers:

Coarse crackles.

Rationale :

💁‍♂️Pneumonia causes inflammation and fluid accumulation within the alveoli and small airways.

💧Air moving through fluid and respiratory secretions produces crackling sounds during auscultation.

👉Because the infection involves the right lower lobe, coarse crackles are most likely to be heard over that anatomical area.

🩺The nurse may also identify decreased breath sounds, bronchial sounds, or increased tactile fremitus over consolidated lung tissue.

📌Core Message

Lobar pneumonia commonly produces coarse crackles because air moves through fluid and secretions in the affected lung region.

Answer 8

Correct Answers:

Begin with questions that are less sensitive in nature.

Rationale :

🤝Beginning with less sensitive questions helps establish rapport and trust between the nurse and the client.

🧠Once the client feels comfortable, the nurse can gradually introduce questions about alcohol and substance use.

⚖️Questions should be asked in a nonjudgmental, direct, and matter-of-fact manner to promote honest disclosure.

🔒The nurse should also provide privacy and confidentiality within appropriate legal and safety limits.

📌Core Message

A successful substance-use interview begins with less sensitive topics and progresses respectfully toward direct, confidential questions.

Answer 9

Correct Answers:

Obtain a baseline set of vital signs.

Rationale :

🩺Obtaining routine vital signs is a standard task that can be delegated to trained unlicensed assistive personnel.

🥼The nurse remains responsible for interpreting the results and responding to any abnormal vital signs reported by the UAP.

🧠Assessing the chief complaint, suicide risk, and domestic violence requires professional nursing judgment and therapeutic interviewing.

🚨Because the client has depression and unexplained fractures, the nurse must personally conduct the psychosocial and safety assessments.

📌Core Message

The UAP may obtain baseline vital signs, while the nurse must perform assessments involving judgment, safety risk, and sensitive communication.

Answer 10

Correct Answers:

Migrant workers who plant and harvest field crops.

Rationale :

🌾Migrant agricultural workers often experience occupational exposure to pesticides, extreme temperatures, injuries, and inadequate sanitation.

🚚Frequent relocation may limit access to continuous healthcare, insurance coverage, transportation, and preventive services.

🗣️Language differences, immigration concerns, poverty, and unfamiliarity with available resources may create significant healthcare barriers.

🏥These combined vulnerabilities create a strong need for local public health outreach, screenings, immunizations, education, and accessible treatment.

📌Core Message

Migrant agricultural workers have the greatest public health need because they face substantial occupational risks and limited access to consistent healthcare 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 :
A nurse is caring for a client.

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 : A nurse is caring for a client.

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 :
A nurse is caring for a client.

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?