NUR 297 Exam 2 Questions

Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient's short-term goals?

documenting patient assessment findings in the patient chart

Which nursing intervention is most important to complete before giving medication to a patient?

double check the patients allergies before giving the drug

Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued?

encourage the patient to rest between bathing activities

Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"?

goal met; pt ambulated three times in the hallway without SOB

Which action is a part of the evaluation step in the nursing process? (Select all that apply.)

identifying the need for modification to the care plan, reviewing whether a patient met their short term goal

What is the most significant problem that may result from improperly written nursing diagnostic statements?

lack of direction for improving pt plan of care

An older client is admitted to the hospital with severe diarrhea. The registered nurse is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit?

orthostatic hypotension

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)

potential communication barriers, diverse cultural practices, scope of nursing practice, functional status of the pt

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.

set the room temp at a comfortable level, remove distracting objects from the interviewing area, ensure comfortable seating at eye level for the client and nurse

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

tests the 6 cardinal positions of gaze

The RN is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response?

the client is treating the nurse with respect

Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)

thoroughly review the pts medical history, analyze the nursing assessment data to determine whether information is complete, consider potential complications or risks for the patient

Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention?

transporting a patient to the hospital entrance for discharge

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

wheezes

When making assignments to a team consisting of a registered nurse (RN), one licensed practical nurse (LPN), and two unlicensed assistive personnel (UAP), which is the best client for the LPN?

a client with a spinal cord injury requiring urinary catheterization every 6 hours as prescribed

the nurse is performing a neurological assessment on a client and elicits a positive rombergs sign. the nurse makes this determination based on which observation

a significant sway when the client stands erect with feet together arms at the side and eyes closed

The RN use the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which findings is the RN assessing when requesting the client to count by 7's?

attention to detail

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply

auscultating lung sounds, obtaining the clients temperature, obtaining information about the clients respirations