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. "Picture yourself in one of your favorite places." This statement is related to visualization, which is a different technique, not specifically meditation.

B. "Choose a word to help focus your attention." Mantra meditation involves repeating a word or phrase to enhance focus and promote relaxation.

C. "Quickly inhale deeply and hold your breath for 30 seconds." Holding the breath for 30 seconds can increase anxiety rather than reduce it. Meditation encourages slow, deep breathing, not breath-holding.

D. "Plan for 1 hour of meditation for each session." Meditation can be beneficial even if done for a few minutes. For beginners, shorter sessions (e.g., 5–10 minutes) are recommended.

A. Attach a probe carefully to the client's finger to prevent discomfort. B. Apply a sensor pad to the client's forehead. C. Secure a probe to one of the client's toes. D. Obtain a pulse oximetry reading when peripheral edema has decreased.

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.

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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 planning teaching about meditation for a client who reports feeling anxious. Which of the following statements should the nurse Include in the teaching?

Correct Answer is B

Explanation

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 assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

A nurse is caring for a client who reports burning around the peripheral IV site. Which of the following findings should the nurse identify as a manifestation of infiltration?

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A nurse is caring for a client who has just learned that their partner died. Which of the following actions should the nurse take first?

A nurse is reviewing the laboratory report of a client who has been experiencing a fever for the last 3 days. Which of the following laboratory results indicates the client is experiencing fluid volume deficit?