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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Free Nursing Study Resources

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.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

i. Clean the puncture site with antiseptic and allow it to dry helps reduce the risk of infection and ensures an accurate reading by preventing contamination.

ii. Wipe away the first drop of blood before collecting the sample is the best next step because the first drop may contain tissue fluid, which can affect glucose accuracy.

Incorrect answers:

Warming the client's hand before performing the fingerstick improves blood flow, making it easier to obtain an adequate sample, especially in clients with diabetes who may have impaired circulation.

Massage the finger gently from the base toward the tip before puncturing promotes blood flow but should be done carefully to avoid excess squeezing, which can lead to inaccurate results.

Ensure the client's hand is below heart level when obtaining the sample encourages blood flow, making collection easier.

Apply firm pressure to the site after obtaining the sample prevents excessive bleeding and helps close the puncture site.

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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 caring for a client in the emergency department. Exhibits Complete the following sentence by using the list of options. When obtaining a capillary blood sample for glucose testing, the nurse should dropdown, and then dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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