A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

"Contacted the provider to report client findings."

"Reports stomach pain as 3 on a pain scale of 0 to 10."

"Vomited 120 mL of clear, yellow emesis."

"Denies further nausea or vomiting since antiemetic administration.

Answer and Explanation

The Correct Answer is D

A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.

B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.

C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).

D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).

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Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

A. Pulse oximetry reading of 95% B. Decreased depth of respirations C. Flaring of the nostrils D. Respiratory rate of 16/min

Correct Answer is C

Explanation

A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.

B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.

C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.

D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.

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A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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