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caring/ intervention
safety
Chapters 26-31: Health
Assessment/Data
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100

A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it.

I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process?

  1. Assessment 
  2. Planning
  3. Intervention
  4. Evaluation

Assessment 

100

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (Select all that apply.)

[]The client's full name

[]The client's date of birth

[]The client's telephone number

[]The dient's diagnosis

[]The dient's room number

[]The client's full name

The client's date of birth

The client's telephone number


100

A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply)

A. Posture

B. Skin lesions

C. Speech

D. Allergies...

  1. CORRECT: Posture is part of the body structure or general appearance portion of the general survey
  2. CORRECT: Skin lesions are part of the body structure or general appearance portion of the general survey
  3. CORRECT: Speech is part of the behavior portion of the general survey
200

During evaluation, the nurse must gather information about the client to

  1. identify whether the client outcomes have been met.
  2. organize resources to proceed with implementing interventions.
  3. establish client-centered outcomes that are measurable and realistic.
  4. determine the priority of care and appropriate interventions.

identify whether the client outcomes have been met.

200

A nurse is collecting data for a client's comprehensive physical examination.

After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next?

A. Olfaction

B. Ausculation

C. Palpation

D. Percussion

B. CORRECT: Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next and before using those two techniques

300

A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (Select all that apply.)

  1. Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain.
  2. Insert an NG tube to relieve a client's gastric distention.
  3. Show a client how to use progressive muscle relaxation.
  4. Perform a daily bath after the evening meal.
  5. Reposition a client every 2 hr to reduce pressure ulcer risk.
  • Show a client how to use progressive muscle relaxation.
  • Perform a daily bath after the evening meal.
  • Reposition a client every 2 hr to reduce pressure ulcer risk.
300

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature?

A. Palmar surface

B. Fingertips

C. Dorsal surface

D. Base of the fingers

C. CORRECT: The dorsal surface of the hand is the most sensitive to

temperature

400

A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (Select all that apply.)

  1. Respiratory rate of 22/min with even, unlabored respirations
  2. "I can only walk three blocks before my legs start to hurt."
  3. Pain level 3 on a scale of 0 to 10
  4. Skin pink, warm, and dry
  5. Urine outout of 300 mL/8 hr
  6. Dressing clean, dry, and intact

*Respiratory rate of 22/min with even, unlabored respirations

  • Skin pink, warm, and dry
  • Urine outout of 300 mL/8 hr
  • Dressing clean, dry, and intact


400

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

A. Request a prescription for an antihypertensive medication

B. Ask the client if she is having pain

C. Request a prescription for an antianxiety medication

D. Return in 30 min to recheck the client's blood pressure

B. CORRECT: The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the nurse's priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider

500

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process?

  1. Reassess the client to determine the reasons for unsatisfactory pain relief.
  2. See whether the pain lessens during the next 24 hr.
  3. Change the plan to ensure that the client achieves adequate pain relief.
  4. Teach the client about the plan of care for managing his pain.

Reassess the client to determine the reasons for unsatisfactory pain relief.

500

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)

A. Capillary refill less than 3 seconds

B. 1+ pitting edema in both feet

C. Pale nail beds in both hands

D. Thick skin on the soles of the feet

A. CORRECT: The nurse should expect capillary refill in less than 3 seconds as an expected finding

D. CORRECT: The nurse should expect thicker skin on the palms of the hands and the soles of the client's feet