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 Korotkoff sounds are difficult to hear, using the palpatory method helps the nurse identify the systolic pressure by palpating the radial pulse as the cuff is inflated and deflated.

📉This technique is useful in clients with low cardiac output, hypotension, or weak pulse, where auscultation is unreliable.

🎯It ensures that the cuff is not overinflated and that subsequent auscultation can be more precise by knowing the expected systolic range.

🔊This method also prevents false readings and minimizes discomfort caused by prolonged cuff inflation or repeated attempts.

📌Core Message

Palpatory method helps determine systolic pressure when Korotkoff sounds are faint or absent, improving accuracy in difficult assessments.

Answer 2

Correct Answers:

Hypertension.

Rationale :

💓Hypertension is a significant contraindication to combination oral contraceptives (COCs) because estrogen can increase the risk of thromboembolic events, stroke, and myocardial infarction in individuals with elevated blood pressure.

⚠️Using COCs in clients with uncontrolled or poorly managed hypertension can place them at higher risk for cardiovascular complications due to estrogen-induced vasoconstriction and fluid retention.

🧬COCs are generally avoided in clients with known vascular or cardiac risks to prevent worsening of these conditions.

📚Other listed conditions like fibromyalgia, fibrocystic breast disease, or renal calculi are not direct contraindications, making hypertension the most critical teaching point in this context.

📌Core Message

Hypertension is a key contraindication to combination oral contraceptives due to increased risk of thromboembolic and cardiac events.

Answer 3

Correct Answers:

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

Rationale :

🩹After an appendectomy, effective pain management is essential for promoting comfort, mobility, and respiratory function, especially in the first 24 hours post-op.

🕒Administering analgesics on a scheduled basis (rather than PRN) ensures consistent pain relief, which can prevent breakthrough pain and allow for earlier ambulation and deep breathing exercises.

😷Uncontrolled pain can lead to shallow breathing, atelectasis, and delayed recovery, especially in school-age children who may underreport pain.

📋This approach reflects evidence-based postoperative care for pediatric surgical clients, promoting comfort and reducing complications.

📌Core Message

Scheduled pain control within the first 24 hours post-op supports effective recovery and comfort in school-age children after surgery.

Answer 4

Correct Answers:

Hematuria

Rationale :

🔬Acute glomerulonephritis involves inflammation of the glomeruli, often triggered by an immune response following infections like streptococcal pharyngitis.

🧪This inflammation increases glomerular permeability, allowing red blood cells to pass into the urine, resulting in hematuria, a hallmark symptom.

🚽Clients typically present with tea-colored or cola-colored urine, which indicates the presence of blood and helps distinguish this condition from other renal disorders.

📈Additional expected findings include edema, hypertension, and decreased urine output—not hypotension, polyuria, or weight loss.

📌Core Message

Hematuria is a classic sign of acute glomerulonephritis due to increased glomerular permeability from inflammation.

Answer 5

Correct Answers:

Digoxin 0.25 mg PO daily

Rationale :

✅A complete medication prescription must include the medication name, dose, route, frequency, and, when needed, specific parameters or duration.

💊The prescription for Digoxin 0.25 mg PO daily meets all these criteria: it includes the drug name (Digoxin), dose (0.25 mg), route (PO), and frequency (daily).

⚠️Other options are missing at least one critical element: for example, Cimetidine lacks a dose, Epoetin alfa lacks a route, and Tetracycline lacks frequency, rendering them incomplete and potentially unsafe.

🔎Prescriptions that are not complete increase the risk for medication errors, especially during transcription or administration.

📌Core Message

Complete prescriptions must include drug, dose, route, and frequency—ensuring safe and accurate medication administration.

Answer 6

Correct Answers:

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

Rationale :

🧠Informed consent is a voluntary process, and the client retains the right to withdraw consent at any time, even immediately prior to the procedure.

🤝By stating, “You don’t have to go through with the treatment,” the nurse supports the ethical principle of autonomy, allowing the client to make her own healthcare decisions.

🧾This response also encourages open communication, ensuring the client feels respected and not coerced into a procedure she is unsure about.

📚Other responses minimize the client’s concerns or promote the treatment without acknowledging her right to decline, which would violate patient-centered care principles.

📌Core Message

Respecting autonomy means acknowledging the client's right to withdraw consent for treatment—even at the last minute.

Answer 7

Correct Answers:

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

Rationale :

👀Sitting at or below the client’s eye level during feeding helps the nurse observe the client’s facial expressions, coordination, and swallowing effort closely, which is vital for clients with dysphagia.

🧠This position enhances communication and safety, allowing the nurse to detect early signs of aspiration such as coughing, throat clearing, or changes in voice.

🧃Proper posture and head position—typically chin-down, not chin-up—are essential in preventing aspiration; thus, lifting the chin is incorrect.

🚫Discouraging coughing is unsafe, as coughing is a natural protective reflex to clear the airway, and talking during feeding can increase the risk of choking or aspiration.

📌Core Message

Proper nurse positioning enhances safety by allowing close monitoring of swallowing in clients with dysphagia.

Answer 8

Correct Answers:

"Advance directives can be signed without legal representation."

Rationale :

🖋️Advance directives, such as living wills or durable powers of attorney for healthcare, are legal documents that can typically be completed without the need for an attorney.

💬The nurse is correct in clarifying that legal representation is not a requirement, which helps reduce the client's anxiety and encourages autonomy in healthcare decision-making.

📚While laws vary slightly by state, in most jurisdictions, these forms require only witnesses or a notary, not legal counsel, to be valid.

💡By providing this accurate information, the nurse is promoting client rights, reducing unnecessary barriers, and supporting informed participation in future medical planning.

📌Core Message

Advance directives can be legally completed without a lawyer, supporting autonomy and accessibility in healthcare planning.

Answer 9

Correct Answers:

Partial separation of the upper part of the incisional line

Rationale :

🚨Partial separation of an incision, also known as dehiscence, is a potentially serious complication that must be reported to the provider immediately to prevent further wound breakdown or infection.

🩹This finding suggests the wound is not healing properly, which can result from tension, infection, or poor nutritional status.

📉Early recognition allows for prompt interventions such as applying sterile dressings, reducing strain, or surgical consultation to prevent complete dehiscence or evisceration.

🩺In contrast, crusting exudate, pink coloration, and mild swelling are expected signs of normal healing and do not require urgent medical intervention.

📌Core Message

Partial separation of a surgical incision indicates dehiscence, requiring immediate provider notification to prevent complications.

Answer 10

Correct Answers:

The client is oriented times three.

Rationale :

✅A Glasgow Coma Scale (GCS) score of 15 represents the highest possible level of consciousness, indicating that the client is fully alert, oriented, and responsive.

🗣️This score reflects the best responses in the three GCS categories: eye opening (4), verbal response (5), and motor response (6).

📋Being oriented to person, place, and time (oriented ×3) earns the highest verbal score, while obeying commands gives the best motor score and spontaneous eye opening the best eye score.

🚫Responses like withdrawing from pain, opening eyes to sound, or being unable to follow commands would result in lower GCS scores, indicating some level of impaired consciousness.

📌Core Message

A GCS score of 15 indicates full alertness, including the ability to be oriented to person, place, and time.

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?

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?