A nurse is preparing to teach clients. Which client finding will cause the nurse to postpone a teaching session? (Select all that apply)

The client is currently febrile with an oral temperature of 101.2°F

The client is mildly anxious about their condition.

The client is reporting feeling nauseated

The client's pain rated 8 out of 10 on a numerical scale

The client is asking questions about their health status.

Answer and Explanation

Correct Answer : A,C,D

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

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Correct Answer is E

Explanation

A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.

A. Edema B. Shortness of breath C. Increase in appetite D. Extreme weight loss E. Jugular vein distended (enlarged)

Correct Answer is ["A","B","E"]

Explanation

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

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A nurse is preparing to teach clients. Which client finding will cause the nurse to postpone a teaching session? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Correct Answer is E

Explanation

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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