NR 206 Analyzing Data to Make Accurate Clinical Judgments

The result of a nursing assessment is the prescription of treatment. formulation of nursing diagnoses. documentation of the need for a referral. client's physiologic status.

formulation of nursing diagnoses.

When assisting a client with health promotion, what must the nurse also nurture? A healthy environment School/work attendance Knowledge of the Healthy People 2020 indicators Family communication

A healthy environment

What are nurses able to detect through the health assessment? Areas that need in-hospital care Areas in need of health adjustments Areas that need continuous care Areas that need referral to a specialist

Areas in need of health adjustments

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take? Hold the medication. Ask the client if they have allergies. Double-check in the admission notes for allergies. Administer the medication.

Ask the client if they have allergies.

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? Evaluate the outcome. Administer IV fluids. Reevaluate the nursing plan. Assess the client.

Assess the client.

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

Evaluation

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of the Department of Health and Human Services the nursing process the three levels of preventative care Healthy People 2030

Healthy People 2030

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose? Identify in what areas the client can educate the family. Identify conditions that the health care provider may have missed. Identify in what areas the client needs the most care. Identify the client's medical diagnosis.

Identify in what areas the client needs the most care

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? Active listening Therapeutic communication Interviewing Inspection

Inspection

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? Initial Focused Ongoing Emergency

Ongoing

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? To establish a database against which subsequent assessments can be measured To establish rapport with the client and family To gather information for specialists to whom the client might be referred To quantify the degree of pain a client may be experiencing

To establish a database against which subsequent assessments can be measured

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next? Ask the client if they need any assistance with the inhalers. Leave the inhalers with the client to self-administer. Provide privacy for the client to administer the inhalers. Validate that the client understands how to use the inhalers.

Validate that the client understands how to use the inhalers.

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time? focused emergency ongoing or partial comprehensive

emergency

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next? assessment diagnosis planning evaluation

evaluation

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) initial comprehensive assessment. ongoing or partial assessment. emergency assessment. focused or problem-oriented assessment.

focused or problem-oriented assessment.

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Click to highlight the findings that will require follow-up. Client is awake, alert, and oriented . Client walks with a cane. Abdomen is soft and nontender, last bowel movement was charted 7 days ago . No urine output has been charted in the last 24 hours . Skin is warm, dry, pink, and intact . Vital signs: temperature, 97.9°F (36.6°C); heart rate 120 beats/min and irregular ; oxygen saturations 88% on room air .

last bowel movement was charted 7 days ago. No urine output has been charted in the last 24 hours. heart rate 120 beats/min and irregular; oxygen saturations 88% on room air.

What are the areas of independent nursing practice? Select all that apply. Deciding when physical procedures should be performed on a client Deciding which medications to administer to the client Deciding what diagnosis a client has Deciding what client teaching is necessary Deciding when a client needs to be turned

Deciding what client teaching is necessary Deciding when a client needs to be turned Deciding when physical procedures should be performed on a client

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment? Empathy Palpation Sympathy Inspection

Empathy

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse? Perform a comprehensive assessment. Update the plan of care. Evaluate patient outcome. Develop a nursing diagnosis.

Evaluate patient outcome

Which of the following is the best example of assessment in everyday life? Listening to a favorite song to relax in the evening Measuring the remaining tread on a car tire to determine whether it is time to replace it Taking the dog for a walk in the park to get exercise Texting a friend to let her know that you made it home safely

Measuring the remaining tread on a car tire to determine whether it is time to replace it

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? Ongoing or partial Focused or problem-oriented Initial comprehensive Emergency

Ongoing or partial

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following? "Fortunately, assessment only needs to be done at the beginning of your stay." "I'm sorry, but assessment is ongoing and continuous." "I'll just need to evaluate you once more, at the end of your stay." "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end."

"I'm sorry, but assessment is ongoing and continuous."

The nurse is exhibiting critical thinking in which client care situation? Transcribing medication orders onto the nurse's medication administration record. Performing a focused assessment on a client who is complaining of shortness of breath. Notifying the healthcare provider of a critical lab result. Answering the client's call bell alarm while the nursing assistant is at lunch.

Performing a focused assessment on a client who is complaining of shortness of breath.