Week 1

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? A. "The grocery store in my neighborhood went out of business." B. "The landlord of my apartment is putting in an access ramp for wheelchairs." C. "I work with a lot of toxic chemicals in my job." D. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

A. "The grocery store in my neighborhood went out of business." Rationale: Social determinants of health include availability of resource to meet daily needs, such as healthful foods.

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she did not like the way she felt."

A. "When I eat shrimp, my tongue swells and I have trouble breathing." Rationale: An allergy to iodine or shellfish indicates a risk for a reaction to the agents used to clean the surgical area. With this knowledge about the client, the nurse must intervene immediately. All other statements can be responded to after addressing the shrimp allergy.

Which client does the nurse identify at greatest risk for slow wound healing? A. A 47-year-old man with obesity and diabetes B. A 58-year-old woman who smokes 2 packs of cigarettes daily C. A 78-year-old man with controlled hypertension D. A 21-year-old woman with an STI

A. A 47-year-old man with obesity and diabetes Rationale: Obesity and diabetes significantly place a client at greatest risk for slow wound healing.

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A. Begin practicing leg exercises prior to surgery. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch. Rationale: Teaching regarding postoperative leg exercises should include having the client begin practicing the exercises before surgery; repeating the exercises several times daily for each leg; pushing the ball of the foot into the bed until the calf and thigh muscles contract; discontinuing exercises and contacting the surgeon if pain of warmth in the calf is present; and pointing toes of one foot towards the bottom of the bed, then towards the face, and switching.

In the early postoperative period, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

A. Blood pressure of 142/90 Rationale: An increase in back pain can be indicative of an epidural hematoma; therefore, the nurse will immediately address this finding. Blood pressure can be compared to baseline after addressing the back pain, as can the headache. The nurse can continue to monitor the expected, gradual return of motor function.

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. A. Caring B. Teaching C. Collaborating D. Advocating E. Researching F. Prescribing

A. Caring B. Teaching C. Collaborating D. Advocating E. Researching Rationale: The generalist nurse's roles include caring, teaching, collaborating, advocating, and researching. Prescribing is a role of health care providers such as physicians, physician assistants, and advance practice registered nurses (APRNs).

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients Rationale: Knowledge and experience of the health care professional influence client outcomes. Other factors that directly influence client outcomes include:· Behavioral and social determinants of health: What "health" means to each client within the context of his or her culture· New approaches to population health management: evidence-based care that is delivered to individuals, communities, and populations· Policy and health care reform: legislation at all levels of government, which influence health care as a right rather than a privilege· Available and emerging technologies: the use of which assesses for health risks and influences treatment plans· Interprofessional practice: the collaboration of all health care team members who are focused on patient-centered care· Shift towards systems thinking: the recognition that health maintenance, health care activities, and health care interventions do not occur in isolation, and that lessons can be learned from individual care that pertains to a larger group of patients (and vice versa).

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? A. Determining that a new blood pressure reading of 190/100 requires intervention now. B. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90. C. Administering amlodipine 5 mg orally once daily D. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake.

A. Determining that a new blood pressure reading of 190/100 requires intervention now. Rationale: Prioritizing hypotheses is the act of considering all possibilities and determining their relative urgency and risk to the client. The nurse who has determined that a blood pressure reading of 190/100 requires nursing intervention now has performed prioritization. Administering medication and contacting a member of the interprofessional health care team reflects the CJMM process of take action.

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) A. Environment of care B. Taking a client's temperature C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge

A. Environment of care C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge Rationale: The most important part of the CJMM is that another layer—the context of the situation—considers and supports clinical judgment. The factors within this layer, such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge, have a direct impact on clinical judgment.

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor < 3 seconds C. Blood pressure 160/100 D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A. Left arm prosthesis C. Blood pressure 160/100 D. Presence of chest rigidity Rationale: The nurse will report assessment findings of a left arm prosthesis (as this must be addressed prior to surgery); blood pressure of 160/100 (as this is high, which may delay surgery); and the presence of chest rigidity (which is an abnormal finding that may indicate respiratory compromise which could affect whether surgery takes place) to the operative team. The findings of skin turgor of < 3 seconds, adherence to the NPO plan, and a natural concern about payment for surgery do not require reporting to the operative team.

Which environments of care will the nurse recognize as components of the healthcare system? Select all that apply. A. Long term care B. Primary care C. Free standing emergency department D. National League of Nursing E. Patient-centered medical home F. World Health Organization

A. Long term care B. Primary care C. Free standing emergency department E. Patient-centered medical home Rationale: Long term care, primary care, free standing emergency department, and the patient-centered medical home are environments of care. The National League for Nursing and the World Health Organization are not environments of care.

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pin-prick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

A. Perform thorough auscultation of the lungs Rationale: After general anesthesia, which affects the entire body, the priority assessment is to determine that the client's level of consciousness has returned. All other assessment can be performed subsequently.

Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.) A. White blood cell count 14,000 mm3 B. Potassium, 3.9 mEq/L (3.9 mmol/L) C. Creatinine, 1.9 mg/dL (168 mcmol/L) D. Fasting glucose, 80 mg/dL (4.4 mmol/L) E. Sodium, 140 mEq/L (140 mmol/L)

A. White blood cell count 14,000 mm3 C. Creatinine, 1.9 mg/dL (168 mcmol/L) Rationale: The nurse will report a creatinine of 1.9 mg/dL (168 mcmol/L) and a white blood cell count of 14,000 mm3 to the anesthesiologist. These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count).

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" Rationale: The nurse will assess the client's level of pain to determine whether it is increasing, unmanaged, or able to be managed until the next dose of medication is due. Telling the client they cannot have medication for another hour, without conducting an assessment, is inappropriate, as cues to a changing health status could be missed. Starting a pain diary may be an appropriate intervention at a later time, but does not address the client's immediate concern. Providing relaxation exercises may be appropriate, but only after an assessment is conducted to determine the cause of the client's pain.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? A. "I quit smoking 10 years ago." B. "I had a heart attack 4 months ago." C. "I take a multivitamin daily." D. "I drink a glass of wine a night."

B. "I had a heart attack 4 months ago." Rationale: The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.

The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) A. "I will take off my stockings one to three times a day for 30 minutes." B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." D. "These stockings help promote blood flow." E. "I feel like these stockings are compressing my legs just a bit."

B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." Rationale: Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result.

Which client situation reflects the health care system of managed care? A. Client obtains vaccinations at a local community health center that is close to home. B. A client receives an annual physical where the cost has been predetermined as $80. C. A client sees a designed family physician who coordinates all aspects of the client's care. D. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

B. A client receives an annual physical where the cost has been predetermined as $80. Rationale: Managed care is a type of organized delivery of care where costs have been determined by the managed care company and health care providers. Therefore, the client whose fixed cost for a physical at $80 is being treated via managed care.

The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 AM as originally prescribed. B. Adjust the administration time to be given at 10:00 AM. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B. Adjust the administration time to be given at 10:00 AM. Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision.

Which action does the nurse implement for a client with wound evisceration? A. Irrigate the wound with warm, sterile saline. B. Cover the wound with a sterile, warm, moist dressing. C. Replace tissue protruding into the opening. D. Apply direct pressure to the wound.

B. Cover the wound with a sterile, warm, moist dressing. Rationale: Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.

Which nursing action reflects systems thinking? A. Giving report to the next shift including client status B. Developing a quality improvement initiative for respiratory assessment C. Documenting the client's lung sounds each shift D. Reviewing best practice for respiratory assessment

B. Developing a quality improvement initiative for respiratory assessment. Rationale: The goal of systems thinking is to encourage the nurse to develop awareness of the interrelationships that exist between individual care and the overall context of health care safety and quality improvement. Documenting and reporting affect individual patient care. Reviewing best practice reflects improving individual nurse practice. Quality improvement initiatives address the systems level, working to improve assessment within an entire unit and/or facility.

The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) A. Ten pounds (4.5 kg) over ideal body weight B. Takes saw palmetto for benign prostatic hyperplasia (BPH) C. Anesthesia complications experienced by partner D. Currently prescribed methylprednisolone therapy E. Age 59 years F. History of diabetes mellitus

B. Takes saw palmetto for benign prostatic hyperplasia (BPH) D. Currently prescribed methylprednisolone therapy F. History of diabetes mellitus Rationale: The client's risk factors include diabetes mellitus, being on methylprednisolone therapy, and taking an herbal preparation (saw palmetto). Diabetes contributes an increased risk for surgery or postsurgical complications. Methylprednisolone use can decrease the body's ability to fight infection. Any type of herbal preparation has the potential to interfere with anesthesia or recovery.

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) A. Systems thinking is not affected by health policy at the national level. B. The complexity of client care can affect systems thinking. C. Systems thinking shifts the focus from safety to quality in care. D. It is important for the nurse to place all focus on individualized client care. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking.

B. The complexity of client care can affect systems thinking. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking. Rationale: Systems thinking pushes the nurse to look beyond the individualized client to consider the impacts within the health care system as a whole. Systems thinking does allow the nurse to consider the root problems that affect care and fosters interprofessional care. Systems thinking does not shift away from safety, rather it promotes safety through quality-based care. The complexity of care and health policy as local, state, national, and global levels can affect systems thinking.

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority? A. Ensure that the correct procedure is noted in the client's health record. B. Witness marking of the left knee site with the client awake and the surgeon present. C. Communicate with the surgeon confirming the client will have a left knee arthroscopy. D. Verify with the client that a left knee arthroscopy will be performed.

B. Witness marking of the left knee site with the client awake and the surgeon present. Rationale: The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent." Rationale: The nurse will use therapeutic communication to determine the client's underlying concerns. This is accomplished by asking the client if there has been a past history of drug dependence (which may explain the reluctance), what seems most fearful about taking opioids (which gives the nurse the chance to dispel myths), and teaching that there are proper ways of taking opioids (as directed and for a short period of time) that is meant to keep the client from becoming dependent. Asking "why" is nontherapeutic and can shut down the line of communication between the client and nurse, as this approach demands a response. The nurse will not promise to give the patient opioids at this time, as further investigation of the client's concerns are warranted first.

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? A. "It is important to provide care consistent with the client's expectation." B. "I will always consider my client's cultural preferences when delivering care." C. "I have been comparing our rates of infection with other units in the hospital." D. "I will look for the policy about family visitation to show my client."

C. "I have been comparing our rates of infection with other units in the hospital." Rationale: Comparing rates of infection with other units shows the nurse has moved beyond the individual level of care to consider how individual care creates an environment that can be compared with other environments. Although providing care consistent with the client's expectation, considering a client's cultural preference, and educating a client about family visitation are appropriate nursing actions, they address care at the individual - not the systems - level of thinking.

The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective? A. "The wound will completely heal in about 2 months." B. "I should remove the dressing if the wound is draining." C. "I may need to restrict my activities for several months." D. "Some bleeding from the incision is normal for several weeks."

C. "I may need to restrict my activities for several months." Rationale: To protect the integrity of the wound, activities may need to be restricted.

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? A. Clinical judgment is a fixed process. B. Clinical judgment is not required to make an informed decision. C. Clinical judgment is an outcome of critical thinking. D. Clinical judgment happens outside the context of the scenario.

C. Clinical judgment is an outcome of critical thinking. Rationale: Clinical judgment, as defined by the National Council of State Boards of Nursing, is the observed outcome of critical thinking and decision making. It is an iterative process (not fixed) that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.

As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action? A. Have the client sign the form. B. Contact the anesthesiologist. C. Contact the surgeon. D. Explain the procedure.

C. Contact the surgeon. Rationale: The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.

Which nursing element reflects systems thinking at the global level of practice? A. Facility health policy B. Quality improvement initiative C. Determinants of health D. Interprofessional practice

C. Determinants of health Rationale: Systems thinking can exist globally, nationally, or locally. An example of global level systems thinking is the determinants of health as these are elements of health that are developed on a global level in relation to population health.

The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food nor water since 9:00 PM last night

C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday Rationale: A diffuse rash could be an indication of a health deviation that must be assessed before surgery. Taking aspirin (or any other medication that anticoagulates) is generally not permitted for a certain period of time before surgery. Therefore, the nurse will notify the surgeon and anesthesia provide of both of these assessment findings. A blood pressure of 130/72 and a serum potassium of 3.5 mEq/L are normal findings, as is the adherence of the client who has not had food nor water for the recommended time before surgery.

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) A. Designing nursing care with a focus on keeping the client safe B. Participating on a committee that is evaluating the newest bar-code scanner C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options E. Referring to a nursing journal to consider trends in care F. Using data collected over the past quarter to determine if and how nursing care should change

C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options Rationale: The QSEN competency of Patient-Centered Care recognizes that the client, with his or her own autonomy, is at the center of all decision making related to care. Respecting the client's preferences about treatment, and including the client in discussions about dietary choices, reflects patient-centered care.

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? A. Medical home B. Community health care C. Inpatient care D. Rehabilitation care

C. Inpatient care

A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed? A. Restraints due to naloxone causing agitation B. Activation of the Rapid Response Team C. Supplemental pain medication D. External pacing to regular heartbeat

C. Supplemental pain medication Rationale: Supplemental pain medication will be anticipated, as reversal of the opioid via naloxone reduces the analgesic effect also.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Call the legal department to draft the paperwork. B. Thank the adult child for sharing the parent's desires. C. Talk to the client to be sure of their wishes. D. Document the conversation in the electronic health record.

C. Talk to the client to be sure of their wishes. Rationale: The nurse would first talk to the client in order to determine the client's wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such.Once the nurse has assessed that the client has certain end-of-life wishes, the nurse can confirm that the client wants these officially documented. If the client agrees, then the legal department can be contacted. Finally, the nurse can thank the adult child for sharing that the client has thoughts about life support, as this was the catalyst that allowed the nurse to further assess the client's wishes. The nurse could not act on the adult child's indications alone.

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse? A. "I will have a bandage on my chest." B. "My family will not be able to see me right away." C. "I will wake up with a tube in my throat." D. "Pain medication will take away all of my pain."

D. "Pain medication will take away all of my pain." Rationale: The client's statement that, "Pain medication will take away all of my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? A. Medical home B. Inpatient care C. Long-term care D. Community Health Center

D. Community Health Center Rationale: Community health care incorporates the model of primary care delivery with a population-based approach. It is within this system of care, at the community health center level, that the most people can be immediately reached in order to receive a new vaccine first. Later, the vaccine may be introduced at specialized points of care such as inpatient care, long-term care, and the medical home.

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? A. Assistive personnel B. Physical therapist C. Licensed social worker D. Occupational therapist

D. Occupational therapist Rationale: The occupational therapist helps clients develop, recover, improve, and maintain ADLs through therapy.

A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery? A. Diagnostic B. Cosmetic C. Curative D. Palliative

D. Palliative Rationale: Colostomy surgery is categorized as palliative. Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature.

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? A. Generate solutions B. Take actions C. Recognize cues D. Prioritize hypothesis

D. Prioritize hypothesis Rationale: The step of the CJMM that correlates with analysis in the nursing process is to prioritize hypothesis. Also, within this step is analyzing cues. Recognizing cues is assessment, generating solutions is planning, and taking action is implementation.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon? A. Sanguineous drainage at the suture site B. Crusting along the incision line C. Serosanguineous drainage on the dressing D. Redness and swelling around the incision

D. Redness and swelling around the incision Rationale: The nurse's concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment? A. Pain at the surgical site B. Verbal stimuli needed to awaken C. Sore throat upon swallowing D. Snoring sounds when inhaling

D. Snoring sounds when inhaling Rationale: Snoring sounds when inhaling may indicate respiratory depression.

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) A. Administers IV furosemide 40 mg as prescribed. B. Sets a goal for client to resume normal activities within 4 weeks following surgery. C. Compares temperature at 0600 with temperature taken at 1200. D. Contacts health care provider after obtaining blood pressure of 200/100. E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum.

E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum. Rationale: Assessment involves observing what the client says subjectively, and what the nurse observes objectively. Collecting information about how a client sustained an injury and noting a pressure injury are examples of assessment.