Health Assessment Review

Role Delegation

100

8. You are listening as one of your co-workers, an RN, giving out assignments to her team with includes 2 LPN/LVN's and 2 nursing assistants. You know that one of the tasks she is assigning to the CNA should only be done by a licensed nurse. What should you do? a. Tell the charge nurse who is in a meeting. b. Discuss it at the next staff meeting c. Openly ask her about it and tell her that she is wrong and report her. d. Discuss with her why the task is not appropriate for the CNA.

What is D) Discuss with her why the task is not appropriate for the CNA.

200

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? 1. A 58-year old on airborne precautions for tuberculosis (TB) 2. A 68-year old just returned from bronchoscopy and biopsy 3. A 72-year old who needs teaching about the use of incentive spirometry a 69-year old with COPD who is ventilator dependent

What is ANS: 3 Rationale: Many surgical patients are taught about coughing, deep breathing, and use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-effeciency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

300

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply) 1. Auscultate breath sounds 2. Administer medications via metered-dose inhaler (MDI) 3. Complete in-depth admission assessment 4. Initiate the nursing care plan 5. Evaluate the patient's technique for using MDI's

What is ANS: 1, 2, 4 Rationale: The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN. Independently completing the admission assessment, initiating the nursing care plan, and evaluating a patient's abilities require additional education and skills. These actions are withing the scope of practice of the professional RN

400

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? 1. Observe how well the patient performs pursed-lip breathing 2. Plan a nursing care regiment that gradually increases activity intolerance 3. Assist the patient with basic activities of daily living 4. Consult with the physical therapy department about reconditioning exercises

ANS: 1 Rationale: Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to a nursing assistant. Planning and consulting require additional education and skills, appropriate to an RN

500

You are acting as preceptor for a newly graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide care to which patients? (Select all that apply) 1. A 38-year old with moderate persistent asthma awaiting discharge 2. A 63-year old with a tracheostomy needing tracheostomy care every shift. 3. A 56-year old with lung cancer who has just undergone left lower lobectomy 4. A 49-year old just admitted with a new diagnosis of esophageal cancer.

What is ANS: 1, 2 Rationale: The new RN is at an early point in her orientation. The most appropriate patients to assign to her are those in stable condition who require routine care. The patient with the lobectomy will require the care of a more experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. As the new nurse advances through her orientation, you will want to work with her in providing care for these patients with more complex needs

Nursing Process

100

The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

What is A) "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

200

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

What is D) Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

300

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

What is A) The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

400

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

500

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

What is What is B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Lab Values

100

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

What is B) Hypocalcemia

200

The nurse evaluates which of the following clients to be at risk for developing hypernatremia? A) 50-year-old with pneumonia, diaphoresis, and high fevers B) 62-year-old with congestive heart failure taking loop diuretics C) 39-year-old with diarrhea and vomiting D) 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

What is A) 50-year-old with pneumonia, diaphoresis, and high fevers

300

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A. Call the physician and report results B. Question the results and redraw the specimen C. Encourage the client to increase the intake of bananas D. Initiate seizure precautions

What is B) Question the results and redraw the specimen

400

Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? A. Deep tendon reflexes decreasing from +2 to +1 B. Bicarbonate rising from 20 mEq/L to 22 mEq/L C. Urine pH less than 6 D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

What is A) Deep tendon reflexes decreasing from +2 to +1 Explanation A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.

500

The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first? A. Notify the health care provider immediately. B. Tap the cheek about two (2) centimeters anterior to the ear lobe. C. Check the serum calcium and magnesium levels. D. Prepare to administer calcium gluconate IVP.

What is B) Tap the cheek about two (2) centimeters anterior to the ear lobe. These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency.

Head to Toe

100

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding known as? A)Ectropion B)Entropion C)Miosis D)Ptosis

What is D) Ptosis Drooping of the upper eyelids and is an abnormal finding

200

A nurse has explained her intention to conduct Weber's test and Rinne's test. Which is the following pieces of equipment will the nurse require? A)Ophthalmoscope B)Otoscope C) Snellen Chart D)Tuning Fork

What is D)Tuning Fork Weber's test and Rinne's test are performed in order to assess sound conduction; both require a tuning fork

300

You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things? A) Have another nurse verify your suspicions. B) Measure the abdominal girth at the umbilicus. C) Measure abdominal girth at the most distended level. D)Ask the client if they are distended.

What is B) Measure the abdominal girth at the umbilicus

400

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following? a. Pulse deficit b. Pulse amplitude c. Ventricular rhythm d. Heart arrhythmia

What is A) Pulse Deficit

500

This test for epididymitis utilizes passes elevation of the testes to detect for scrotal pain relief.

What is Prehn's sign

Prioritization

100

You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? 1. The patient has fine bibasilar crackles 2. The patient's respiratory rate is 8 breaths/min. 3. The patient sits up and leans over the night table. 4. The patient has a large barrel chest.

What is ANS: 2 Rationale: For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the night table are common in patients with chronic emphysema

200

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? 1. A 68-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab 2. A 57-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. A 72-year old with pneumonia who needs to be started on intravenous (IV) antibiotics 4. A 52-year old with asthma who complains of shortness of breath after using a bronchodilator

What is ANS: 4 Rationale: The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations are urgent. in COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable.

300

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4 F (38.6 C)

What is ANS: 4 Rationale: Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.

400

The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? 1. Reassure the patient that the ventilator will do the work of breathing for him 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm 3. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube

What is ANS: 2 Rationale: Manual ventilation of the patient will allow you to deliver an Fio2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessment of the reason for the high-pressure alarm and resolution of the hypoxemia

500

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotraceal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled 2. Hyperoxygenate the patient before suctioning 3. Maintain the head of the bed at a 30 - to 45-degree angle 4. Suction the airway when coarse crackles are audible

What is ANS: 3 Rationale: Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP