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Questions 149

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Question 1 of 5

The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:

Correct Answer: A

Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.

Question 2 of 5

Which task should be assigned to the nursing assistant?

Correct Answer: C

Rationale: Feeding a client with dementia is within the nursing assistant's scope, as it involves basic care and does not require advanced skills.

Question 3 of 5

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct Answer: C

Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.

Question 4 of 5

The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?

Correct Answer: C

Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity

Question 5 of 5

A student nurse is precepting on the unit and caring for a client with a Dobbhoff nasoenteric tube. Which statement by the student nurse indicates the need for further teaching on caring for a client with this tube? Select all that apply.

Correct Answer: B, C

Rationale: Auscultation is not a reliable method for confirming tube placement; X-ray is required. Mixing medications with feedings can cause clogs or interactions. The other statements are correct.

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