BSN 246 (BSN246)

The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities. (Ans- A, C Which action should the registered nurse (RN) implement to complete an assessment for a client while using ...

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? (Ans- Oral mucosa is cyanotic. While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? (Ans- Ask the client to describe the episodes of dyspnea in more detail. Whe...

A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? (Ans- Inspect the hair and skin. A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? (Ans- Dull, thud-like. The nurse is assessing a hea...

A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? Explain how the nursing skill will be performed before proceeding. Examine client with an additional healthcare provider for support. Request a male nurse or healthcare provider to perform the exam. Avoid any skills that involve touching the client during the exam. (Ans- Request a male nurse or healthcare provider to perform the exam. Rationa...

The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001. Tented skin on dorsal surface of hands. (Ans- Urine output of 40 mL/hour. Rationale A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal...

The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? The client maintains optimal nutritional status. The client will remain alert and oriented. The client will remain free from injury. The client will remain alcohol free during hospitalization. (Ans- The client will remain free from injury. Rationale The client is at highest risk for injur...

The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumption of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose. (Ans- A All alcohol (A) and any foods that contain tyramine should be avoided while taking an M...

A patient with type 2 diabetes who takes oral hypoglycemics at home is admitted to the hospital with an infection and asks why insulin injections have been prescribed. Which explanation would the nurse provide? (Ans- The infection increases the glucose level, resulting in a need for more insulin. The nurse would encourage a patient newly diagnosed with type 2 diabetes to limit intake of which foods to help reduce the percent of fat in the diet? (Ans- Cheese (b/c of fat content) a colle...

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