When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Administer a prescribed antianxiolytic.

Allow the client to rest before taking the vital signs.

Notify the client representative.

Offer the client hot tea to promote relaxation.

Answer and Explanation

The Correct Answer is B

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.
B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.
C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.
D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.

A. Remove the drainage bag and apply antibiotic ointment around the stoma. B. Apply a pulse oximeter to determine the client's oxygen saturation level. C. Replace the colostomy supplies with non-latex hypoallergenic supplies. D. Notify the healthcare provider of the appearance of the stoma immediately.

Correct Answer is D

Explanation

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is D

Explanation

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Correct Answer is D

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?