FON test 4- chp. 2, 13, 21
What is auscultation?
(audio) listening through a stethoscope
The nurse is caring for a client who has had a total knee replacement and has not had a bowel movement on postoperative day three. Which action(s) taken by the nurse is part of the implementation step of the nursing process? Select all that apply.
administer laxatives encourage for more frequent mobilization
Which group of terms best defines assessing in the nursing process?
collection, validation, and implementing nursing interventions
etiology (explanation)
cause of disease
Which type of health problem requires both physician- and nurse-prescribed actions to address?
collaborative health problem
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?
determine if the prescribed treatment was effective
Is the following statement true or false? The first step of the nursing process is planning.
false, it is assessment
When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing?
focused
A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?
health promotion
What is palpation?
touching or feeling with the hand
ADPIE - Nursing Process
Assessment Diagnosis Planning Implementation Evaluation
what do you need for a physical assessment?
Gloves Examination gown/cloth or paper drapes Scale Stethoscope Sphygmomanometer (B/P cuff)
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?
consult with a more experienced nurse.
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?
gastrointestinal upset from food poisoning
A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?
ineffective airway clearance
Which statement regarding critical thinking in nursing is true?
is a systemic way of thinking.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?
physiological
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?
reassess the appropriateness of the method of instruction
What is olfaction?
smelling (ex. urine, feces, c.diff) GI bleed C-DIFF KETONES - DKA
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?
standardized care plan
A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?
subjective data (client says)
A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply.
the client has ample financial resources the client is willing to attend counseling resources
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
the client is normotensive (normal bp)