Prep U Chapter 1
Perform an emergency assessment
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
assess the nasogastric tube for proper functioning
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
emergency
A client admitted with hyperthyroidism develops life-threatening symptoms—high fever (104° F/40° C), tachycardia (150 bpm), and elevated blood pressure (200/105 mm Hg)—prior to receiving radioactive iodine treatment. What type of assessment should the nurse perform on this client?
evaluate patient outcome
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?
"I'm going to asses the client now so I can begin formulating the care plan"
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
airway
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?
emergency
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?
ask the client about the most recent experience of pain
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
assess the client
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?
expansion of health care networks
A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?
ask the client if they have allergies
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?
inspection
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?
making incorrect nursing judgements or diagnoses
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Formation of judgments that may interfere with the interview
A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this client and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?
evaluation
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
ongoing or partial
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?
evaluate outcome
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
to establish a database against which subsequent assessments can be measured
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
a baseline for comparison with future findings
A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides?
ongoing
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?
suspected abuse
An 80-year-old bed-bound client is admitted with altered mental status. The comprehensive nursing assessment reveals the following: ● bruising at different stages of healing ● decreased Body Mass Index indicating malnutrition ● stage 3 pressure ulcer on the coccyx ● cloudy urine with large amounts of bacteria The nurse considers priorities based on the data. Which of the following should be a priority concern for this client?
Focused or Problem-Oriented Assessment
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)
nursing intervention
An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?
arrive at conclusions about the client's health
Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to
Extend the time originally allotted for the completion of the initial health assessment.
Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?
environmental
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
asking the appropriate questions
How does a nurse best facilitate the nursing health assessment?
nurses collaborate with clients to identify areas in which clients are willing to make changes
How does a nurse decide what health-promotion activities are necessary for a particular client?
evaluation
Revising the plan as needed occurs in what part of the nursing process?
conduct a focused assessment
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?
healthy people 2023
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
objective
The client has a murmur. This is what type of data?
objective
The nurse is conducting a physical assessment of a new client. What data does the nurse collect that are measurable?
A. Performing a focused assessment on a client who is complaining of shortness of breath.
The nurse is exhibiting critical thinking in which client care situation?
Validate that the client understands how to use the inhalers
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?
the clients motivation for change
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?
evaluate an outcome
The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?
develop a nursing diagnoses
The nurse reviews the laboratory values of a client and observes a decrease in the client's hematocrit and hemoglobin since admission. The nurse reviews the client's vital sign trend since admission and sees the BP has been decreasing as well. What is the best action of the nurse?
Collecting information about the health status of the client Evaluating client outcomes Synthesizing collected data
The purpose of a health assessment includes what? (Select all that apply.)
evaluation
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?
to treat human responses
What is one of the broad goals within nursing?
comprehensive
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
a healthy environment
When assisting a client with health promotion, what must the nurse also nurture?
identify in what areas the client needs the most care
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?
diagnosis
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
body functions
Which assessment finding should the nurse document as objective data?
Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
Which of the following is the best example of holistic data collection by a nurse?
to achieve the best results
Why is the nurse always reassessing the client for changes?