skills 2

The nurse explains to another nurse the meaning of situational awareness. Which client exemplar does the nurse use to illustrate situational awareness?

"If the call bell has been out of the client's reach, I ask if the client needs to void or defecate."

An emergency room nurse is conducting a quick head-to-toe assessment of a client reporting flu-like symptoms. What pulse grade would the nurse document if the client's radial pulses were "full, easy to palpate, and cannot be obliterated"?

+2 pulse

What assessment would the nurse make prior to using a pulse oximeter to measure oxygen saturation?

Capillary refill.

The nurse is preparing to conduct a 10-minute head-to-toe assessment on a client admitted with pneumonia. What should the nurse do first?

Complete a general inspection.

A 40-year-old female client reports dull pain in the left breast. Before examining the client's breasts, using the wedge method, the nurse places the client in which position?

Dorsal recumbent with the arm of the side being examined above the head

The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first?

Inspect the skin, bones, and muscles of the entire posterior thorax.

The nurse is caring for a client who is being admitted to the intensive care unit with bilateral pulmonary emboli. The client is reporting anxiety and apprehension. What would the nurse do? Select all that apply.

Modify procedures as much as possible to limit stress., Note cultural influences that may influence individual response., Encourage client to express and acknowledge feelings.

The emergency room nurse is conducting a focused thorax and lung assessment on a client reporting chest pain, cough, and dyspnea. Which assessment findings indicate the need for further assessment? Select all that apply.

Observed the client have a moist cough with production of yellow sputum, Auscultated low pitched, bubbling sounds during inspiration in right upper lobe

The nurse is planning to assess an older adult client admitted with abdominal pain. Which special considerations are important to contemplate when assessing the older adult client? Select all that apply.

Older adults take longer to perform certain actions., Presence of heart sound S4 is considered normal., Short term memory may diminish with age.

The nurse on a telemetry unit is assessing oxygen saturation of a client admitted with severe peripheral edema using a pulse oximeter. The nurse obtains a weak and inaccurate pulse oximeter reading. What actions constitute the correct response by the nurse? Select all that apply.

Request a prescription for an arterial blood gas level by the lab., Use an ear pulse oximeter probe on one of the client's ears.

The nurse typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding causes the nurse to perform this assessment rather than delegate it?

The client went to the emergency department to be evaluated after a fall.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

The client's available hemoglobin is adequately saturated with oxygen.

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

There is spilled water on the floor., The IV is not infusing at the correct rate., The client is wearing the oxygen around the neck., The skin is a bluish-color.

The nurse is using a pulse oximeter to monitor a client's oxygen saturation following abdominal surgery to ensure adequate oxygenation. The health care provider has set a parameter of 92%. How would the nurse maintain this parameter?

Adjusting the flow of oxygen to maintain an oxygen saturation level at or above 92%.

The nurse is using a pulse oximeter to monitor a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that which factor might affect the results of pulse oximetry?

Alterations in circulation.

The nurse is performing a quick assessment at the beginning of the shift. During auscultation of the client's lungs, decreased breath sounds, prolonged expiration, and expiratory wheezes bilaterally are auscultated. What would the nurse suspect?

An acute asthmatic exacerbation is occurring

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

The nurse has attached the probe of a pulse oximeter to the finger of a client to monitor oxygen saturation. The nurse notices that the oximeter reads a low saturation of 88 percent with irregular meter pulsations; however, upon assessment of the client, the nurse finds no symptoms of respiratory distress. What might be causing this failure to obtain an accurate reading?

Peripheral vascular disease.

The nurse is completing a quick head-to-toe assessment on a client admitted with right-sided heart failure. Which body parts should be examined for peripheral edema? Select all that apply.

Sacrum, Hands, Feet

The nurse is turning on the pulse oximeter and notices a bar form on the machine. What does this bar represent?

Signal strength.

The nurse is performing a quick head-to-toe assessment on a client admitted with an infected left heel wound. When auscultating the lower lobes of the client's lungs, what might the nurse expect to find?

Soft, low pitched sounds bilaterally