A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Motor impairment

Pain

The client's culture

Hearing loss

Answer and Explanation

The Correct Answer is B

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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Correct Answer is B

Explanation

A. Checking the instrument gauge to ensure it starts at zero is important for accurate readings.

B. Placing the arm above the level of the heart can result in a falsely low blood pressure reading. The arm should be at the level of the heart for an accurate measurement.

C. Wrapping the cuff snugly around the arm ensures a proper fit, which is necessary for accurate readings.

D. The bladder of the cuff should be centered over the brachial artery to obtain the most accurate reading.

A. Inspect B. Palpate C. Auscultate D. Percuss

Correct Answer is A

Explanation

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Correct Answer is B

Explanation

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

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