A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?

Telephone number

Diagnosis

Provider's name

Room number

Answer and Explanation

The Correct Answer is A

Rationale

A. Telephone number: Using the client’s unique identifiers, such as name and date of birth, is standard practice, but if multiple identifiers are required, asking the client to confirm information like a telephone number helps ensure correct identification. Proper identification prevents errors in assessment, medication administration, and procedures.

B. Diagnosis: A client’s diagnosis does not uniquely identify them because multiple clients may share the same condition. Relying on diagnosis alone could lead to misidentification and errors in care.

C. Provider's name: The healthcare provider’s name is not a reliable client identifier. Multiple clients may be under the care of the same provider, so using this information cannot ensure the correct patient is being assessed.

D. Room number: Room numbers are temporary and can change; several clients may share a room at different times. Using room number alone is insufficient to confirm identity and does not meet safety standards for patient identification.

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Correct Answer is C

Explanation

Rationale

A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.

B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.

C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.

D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.

A. Instruct the client to use the incentive spirometer five times per hour. B. Administer ondansetron. C. Encourage the client to splint the abdomen. D. Encourage the client to cough and breathe deeply. E. Administer supplemental oxygen. F. Ambulate the client 30 min after administering analgesia. G. Administer acetaminophen.

Correct Answer is ["A","C","D","E","F"]

Explanation

Rationale

A. Instruct the client to use the incentive spirometer five times per hour: Frequent use of the incentive spirometer promotes lung expansion, prevents atelectasis, and improves oxygenation postoperatively, especially when lung sounds are diminished.

B. Administer ondansetron: Ondansetron addresses nausea but does not directly improve respiratory status. While important for comfort, it is not a primary intervention for pulmonary function.

C. Encourage the client to splint the abdomen: Splinting the incision during coughing or deep breathing reduces pain, allowing the client to perform respiratory exercises effectively and decrease the risk of atelectasis or hypoventilation.

D. Encourage the client to cough and breathe deeply: Deep breathing and coughing mobilize secretions, enhance alveolar ventilation, and prevent postoperative pulmonary complications, which is critical given the client’s diminished lung sounds and shallow respirations.

E. Administer supplemental oxygen: Supplemental oxygen can help improve oxygen saturation in clients with hypoxemia, as indicated by the drop to 92% on room air.

F. Ambulate the client 30 min after administering analgesia: Early ambulation enhances lung expansion, promotes circulation, and helps prevent pulmonary complications. Providing analgesia beforehand minimizes pain and encourages participation.

G. Administer acetaminophen: Acetaminophen may reduce fever and mild pain but does not directly improve respiratory status or lung expansion, so it is not a primary intervention in this scenario.

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A nurse enters a client's room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing fluid volume excess. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Correct Answer is ["A","C","D","E","F"]

Explanation

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