Chapter 29 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 29

Question 1

Type: SEQ

The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the following activities of the nursing process in the proper order.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The nurse educates the client regarding the care of his sternal and leg incisions.

Choice 2. The client is admitted to the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft.

Choice 3. The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection.

Choice 4. The nurse develops a plan to help prevent some of the known complications associated with surgery.

Correct Answer: 2,3,1,4

Rationale 1: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client.

Rationale 2: The second step is to create a nursing diagnosis using NANDA nursing labels.

Rationale 3: The third step is to develop a plan to help the client heal and prevent the development of complications.

Rationale 4: The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurses plan for the client worked.

Global Rationale: The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client. The second step is to create a nursing diagnosis using NANDA nursing labels. The third step is to develop a plan to help the client heal and prevent the development of complications. The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurses plan for the client worked.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client.

Question 2

Type: MCMA

The nurse works on a medical-surgical unit. Which of the following clients will require a rapid assessment?

Standard Text: Select all that apply.

1. The client had an open appendectomy 2 days ago and is preparing to be discharged today.

2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.

3. The client has just been received from the Post Anesthesia Care Unit.

4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.

5. The client begins to complain of difficulty breathing. The clients oxygen saturation level has decreased from 93% on room air this morning to 87%.

Correct Answer: 3,4,5

Rationale 1: The client had an open appendectomy 2 days ago and is preparing to be discharged today. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment.

Rationale 2: The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. The client who has been admitted to the unit the day before and is receiving effective treatment requires a routine assessment.

Rationale 3: The client has just been received from the Post Anesthesia Care Unit. The nurse should perform a rapid assessment on a client following a surgical procedure.

Rationale 4: The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care.

Rationale 5: The client begins to complain of difficulty breathing. The clients oxygen saturation level has decreased from 93% on room air this morning to 87%. The nurse should perform a rapid assessment on a client who is in distress.

Global Rationale: The nurse should perform a rapid assessment on a client following a surgical procedure. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. The nurse should perform a rapid assessment on a client who is in distress. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. The client who has been admitted to the unit the day before requires a routine assessment.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client.

Question 3

Type: MCSA

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which of the following statements by the student nurse indicate that further education is required?

1. The rapid assessment should last approximately 10 minutes.

2. I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care.

3. The rapid assessment will help me establish baseline data about the client.

4. After I perform the rapid assessments on the clients Ive been assigned, I can go back and get more information during my routine assessments.

Correct Answer: 1

Rationale 1: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes.

Rationale 2: It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients.

Rationale 3: The rapid assessment helps the nurse establish baseline data about the client.

Rationale 4: Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client.

Global Rationale: The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. The rapid assessment helps the nurse establish baseline data about the client. Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29.1: Discuss the types of assessment carried out with the hospitalized client.

Question 4

Type: MCMA

The nurse is preparing to assess the general appearance of the hospitalized client. Which of the following statements by the client are expected if the client is experiencing undernutrition?

Standard Text: Select all that apply.

1. It seems like I get catch every bug that comes along. I cant seem to stay well.

2. This wound that Ive had for the last 3 months on my leg wont heal.

3. I have gained 5 pounds over the last week and my ankles and feet are swollen.

4. My nails are so brittle.

5. I know my blood pressure has been up because Ive been experiencing headaches in the morning, just like last time.

Correct Answer: 1,2,4

Rationale 1: It seems like I get catch every bug that comes along. I cant seem to stay well. Undernutrition can lead to a compromised immune status.

Rationale 2: This wound that Ive had for the last 3 months on my leg wont heal. Undernutrition can lead to poor wound healing.

Rationale 3: I have gained 5 pounds over the last week and my ankles and feet are swollen. Edema in the feet and ankles along with weight gain is often associated with a poor cardiovascular status or renal insufficiency. These types of signs are not typically associated with undernutrition.

Rationale 4: My nails are so brittle. Undernutrition can lead to the development of brittle nails and hair.

Rationale 5: I know my blood pressure has been up because Ive been experiencing headaches in the morning, just like last time. The client with hypertension can experience headaches in the morning. Hypertension is not typically associated with undernutrition.

Global Rationale: Undernutrition can lead to a compromised immune status. Undernutrition can lead to poor wound healing. Undernutrition can lead to the development of brittle nails and hair. Edema in the feet and ankles along with weight gain is often associated with a poor cardiovascular status or renal insufficiency. These types of signs are not typically associated with undernutrition. The client with hypertension can experience headaches in the morning. Hypertension is not typically associated with undernutrition.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 29.2: Conduct a rapid and routine assessment of a hospitalized client.

Question 5

Type: MCSA

The student nurse has performed a rapid assessment on the diabetic client and is reporting information back to the experienced nurse. The student nurse notes that the client is experiencing emotional stress following his wifes recent death. Which of the following statements by the nurse student nurse regarding the effects of emotional stress indicate the need for further education?

1. Emotional stress can negatively impact his immune systems ability to function.

2. Hes probably not been eating well recently.

3. I should not ask about his use of drugs or alcohol at this time.

4. He may be hyperglycemic.

Correct Answer: 3

Rationale 1: Emotional stress affects the immune system resulting in increased susceptibility to infection.

Rationale 2: During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals.

Rationale 3: Some individuals use alcohol, tobacco, or drugs to feel better. The nurse must assess the clients use of drugs or alcohol at this time.

Rationale 4: The client who is experiencing emotional stress is more likely to develop an increased serum glucose level due to the increased level of circulating stress hormones.

Global Rationale: Some individuals use alcohol, tobacco, or drugs to feel better. The nurse must assess the clients use of drugs or alcohol at this time. Emotional stress affects the immune system resulting in increased susceptibility to infection. During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals or following an exercise routine. The client who is experiencing emotional stress is more likely to develop an increased serum glucose level due to the increased level of circulating stress hormones.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.2: Conduct a rapid and routine assessment of a hospitalized client

Question 6

Type: SEQ

The nurse is performing an initial assessment on the hospitalized client. The nurse is assessing the clients respiratory system. Rank the following steps in the correct sequence.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The nurse percusses the clients thorax.

Choice 2. The nurse unties the clients gown to better visualize the clients thorax.

Choice 3. The nurse warms his stethoscope and listens to the clients lung sounds in each lung field.

Choice 4. The nurse gently palpates the clients thorax.

Correct Answer: 3,1,4,2

Rationale 1: The first thing that the nurse should do is to perform a visual inspection of the clients thorax.

Rationale 2: The second step is for the nurse to gently palpate the clients thorax.

Rationale 3: The third step is for the nurse to percuss the clients thorax.

Rationale 4: The last step is for the nurse to auscultate the clients lungs.

Global Rationale: When performing a physical assessment, the nurse utilizes four basic techniques to obtain objective and measurable data. These techniques are inspection, palpation, percussion, and auscultation and are performed in an organized manner. This pattern of organization varies when assessing the abdomen. The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 7

Type: MCMA

The nurse is performing a rapid assessment for each of the following clients. Which of the following clients require immediate medical assistance?

Standard Text: Select all that apply.

1. The client is pale and is breathing in a shallow manner.

2. The clients oxygen saturation level is 74% and is dyspneic.

3. The client is rating his pain at a 3 out of a 10 on a pain scale.

4. The client is unable to follow directions.

5. The nurse determines that the clients level of consciousness is decreasing.

Correct Answer: 1,2,4,5

Rationale 1: The client is pale and is breathing in a shallow manner. The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention.

Rationale 2: The clients oxygen saturation level is 74% and is dyspneic. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention.

Rationale 3: The client is rating his pain at a 3 out of a 10 on a pain scale. The client who is complaining of only mild pain does not require immediate medical assistance.

Rationale 4: The client is unable to follow directions. The client who is unable to follow directions should be provided with immediate medical attention.

Rationale 5: The nurse determines that the clients level of consciousness is decreasing. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This clients level of consciousness is decreasing very quickly and indicates a severe problem is occurring.

Global Rationale: The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention. The client who has an oxygen saturation level of 74% and is dyspneic is exhibiting clinical manifestations associated with cardiovascular problems. This client should receive immediate medical attention. The client who is unable to follow directions should be provided with immediate medical attention. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This clients level of consciousness is decreasing very quickly and indicates a severe problem is occurring. The client who is complaining of only mild pain does not require immediate medical assistance.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 8

Type: MCMA

The client is performing an assessment of the hospitalized client. After speaking with the client, the nurse believes that the client is demonstrating altered thought processes. Which of the following statements by the client validate the nurses conclusion?

Standard Text: Select all that apply.

1. When I was little I had 4 cats. Can I wear a dress instead of this hospital gown?

2. I wish that my grandmothers daughter would visit me more often.

3. I have never had so much pain. I just dont feel like speaking with you right now.

4. My doctor has only been to visit me once during the last three days. Im starting to feel angry that she hasnt come to see if Im doing better.

5. Red squirrels dance on the divine divide.

Correct Answer: 1,2,5

Rationale 1: When I was little I had 4 cats. Can I wear a dress instead of this hospital gown? The client who frequently jumps from one subject to another is exhibiting a flight of ideas. Flight of ideas is associated with altered thought processes.

Rationale 2: I wish that my grandmothers daughter would visit me more often. The client who is unable to communicate ideas easily is exhibiting circumlocution. It wouldve been easier for the client to state that he or she wished her mother would visit more frequently.

Rationale 3: I have never had so much pain. I just dont feel like speaking with you right now. The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes.

Rationale 4: My doctor has only been to visit me once during the last 3 days. Im starting to feel angry that she hasnt come to see if Im doing better. It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in three days. This statement does not indicate that the client is experiencing altered thought processes.

Rationale 5: Red squirrels dance on the divine divide. The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad.

Global Rationale: The client who frequently jumps from one subject to another is exhibiting a flight of ideas. Flight of ideas is associated with altered thought processes. The client who is unable to communicate ideas easily is exhibiting circumlocution. It wouldve been easier for the client to state that she wished her mother would visit more frequently. The client who is unable to communicate an idea that makes sense in the context of the situation is exhibiting word salad. The client who is experiencing pain may not feel like communicating with the nurse. This is not an example of altered thought processes. It would be appropriate for the client to feel that the healthcare provider should visit the client more often than once in 3 days.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 9

Type: MCMA

The nurse is performing routine assessments on five hospitalized clients. Which of the following clients does the nurse expect to exhibit poor skin turgor?

Standard Text: Select all that apply.

1. The client had an open appendectomy 2 days ago.

2. The client was admitted with severe nausea and vomiting.

3. The client has lost 16 pounds during the last 30 days.

4. The client has had a high fever during the last four days and was admitted through the Emergency Department last night.

5. The client was admitted this morning with a severe migraine.

Correct Answer: 2,3,4

Rationale 1: The client had an open appendectomy 2 days ago. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time.

Rationale 2: The client was admitted with severe nausea and vomiting. The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration.

Rationale 3: The client has lost 16 pounds during the last 30 days. The client who has lost a large amount of weight will often exhibit poor skin turgor.

Rationale 4: The client has had a high fever during the last four days and was admitted through the Emergency Department last night. The client who has had a high fever will often exhibit poor skin turgor due to dehydration.

Rationale 5: The client was admitted this morning with a severe migraine. The client who has a severe migraine will not necessarily demonstrate signs of dehydration.

Global Rationale: The client who was admitted with severe nausea and vomiting will most likely exhibit signs associated with dehydration. Poor skin turgor is associated with dehydration. The client who has lost a large amount of weight will often exhibit poor skin turgor. The client who has had a high fever will often exhibit poor skin turgor due to dehydration. The client who had an open appendectomy will most likely be prepared for discharge at this time. It is unlikely that this client will exhibit poor skin turgor at this time. The client who has a severe migraine will not necessarily demonstrate signs of dehydration.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 10

Type: MCSA

The client is comatose and the healthcare provider orders that the clients temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the clients temperature. Which of the following statements by the student nurse indicate the need for further education?

1. I will need to turn the client into the prone position.

2. The probe for a rectal thermometer is usually red.

3. I should insert the thermometer 1.5 to 4 centimeters into the clients anus.

4. This is an appropriate way to monitor a clients temperature if they are unable to close the mouth around the oral thermometer.

Correct Answer: 1

Rationale 1: The client should be turned to the side, not the prone position.

Rationale 2: The rectal thermometer probe is usually red to signify that it is different from an oral thermometer probe.

Rationale 3: The thermometer should be placed 1.5 to 4 centimeters into the clients anus.

Rationale 4: This route may be used if the client is unable to close his or her mouth around an oral thermometer probe.

Global Rationale: The client should be turned to the side, not the prone position. The rectal thermometer probe is usually red to signify that it is different from an oral thermometer probe. The thermometer should be placed 1.5 to 4 centimeters into the clients anus. This route may be used if the client is unable to close his or her mouth around an oral thermometer probe.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 11

Type: MCMA

The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the clients oxygenation level and the presence of jaundice. Which of the following statements by the nurse to the client indicate that the nurse is performing these specific assessments?

Standard Text: Select all that apply.

1. I need to look at your eyes.

2. Please open your mouth for me.

3. Squeeze my fingers with your hands.

4. I am going to listen to your belly with my stethoscope.

5. I need to press on your fingernail.

Correct Answer: 1,2,5

Rationale 1: I need to look at your eyes. The nurse should look into the dark-skinned clients eyes to examine the sclera for the presence of jaundice. The nurse can also examine the clients conjunctiva to assess for the presence of pallor and oxygenation status.

Rationale 2: Please open your mouth for me. The nurse should examine the inside of the clients mouth to assess the mucous membranes for the clients oxygenation status.

Rationale 3: Squeeze my fingers with your hands. The nurse should assess the clients neurological status by asking the client to squeeze both of the nurses hands bilaterally.

Rationale 4: I am going to listen to your belly with my stethoscope. The nurse should assess the clients bowel sounds during the gastrointestinal system assessment.

Rationale 5: I need to press on your fingernail. The nurse can assess the clients capillary refill by pressing on the clients fingernails to determine the clients level of oxygenation.

Global Rationale: The nurse should look into the dark-skinned clients eyes to examine the sclera for the presence of jaundice. The nurse can also examine the clients conjunctiva to assess for the presence of pallor and oxygenation status. The nurse should examine the inside of the clients mouth to assess the mucous membranes for the clients oxygenation status. The nurse can assess the clients capillary refill by pressing on the clients fingernails to determine the clients level of oxygenation. The nurse should assess the clients neurological status by asking the client to squeeze both of the nurses hands bilaterally. The nurse should assess the clients bowel sounds during the gastrointestinal system assessment.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 12

Type: MCMA

During the physical assessment of a hospitalized client, the client stated, Ive been under an incredible amount of stress after the healthcare provider diagnosed me with colon cancer 2 days ago. Which of the following findings are associated with increased stress?

Standard Text: Select all that apply.

1. Apical heart rate is 104 beats per minute.

2. Respiratory rate is 16 breaths per minute.

3. Pupils were equal, dilated, and round.

4. Client is hypoglycemic.

5. Blood pressure is 158/94.

Correct Answer: 1,3,5

Rationale 1: Apical heart rate 104 beats per minute. When the client is experiencing increased levels of stress, the apical heart rate increases.

Rationale 2: Respiratory rate 16 breaths per minute. The client with increased levels of stress will have an increased respiratory rate. This is a normal value.

Rationale 3: Pupils were equal, dilated, and round. The client who is experiencing increased levels of stress may exhibit dilated pupils.

Rationale 4: Client is hypoglycemic. The client with increased levels of stress will have an increased serum glucose level. This is a normal value.

Rationale 5: Blood pressure 158/94. The client who is experiencing increased levels of stress may have an increased blood pressure.

Global Rationale: When the client is experiencing increased levels of stress, the apical heart rate increases. The client who is experiencing increased levels of stress may exhibit dilated pupils. The client who is experiencing increased levels of stress may have an increased blood pressure. The client with increased levels of stress will have an increased respiratory rate. The client with increased levels of stress will have an increased serum glucose level.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 13

Type: MCSA

The student nurse has measured the clients oxygen saturation level by using a pulse oximeter. The student nurse confers with the experienced nurse. Which of the following statements indicate the student nurse requires further education?

1. A normal finding is that the clients oxygen saturation level is above 70%.

2. The pulse oximeter can measure the oxygen saturation of the hemoglobin.

3. I placed the sensor on the clients finger.

4. This test is noninvasive and painless.

Correct Answer: 1

Rationale 1: A normal finding is that the clients oxygen saturation is above 95%, not above 70%. A client with an oxygen saturation of only 70% has an increased risk of dying due to complications of poor oxygenation.

Rationale 2: The pulse oximeter measures the oxygen saturation of the clients hemoglobin. The reported percentage represents the light absorbed by oxygenated and deoxygenated hemoglobin.

Rationale 3: The sensor may be placed on the clients finger or earlobe.

Rationale 4: The test is noninvasive and will not cause the client to feel pain.

Global Rationale: A normal finding is that the clients oxygen saturation is above 95%, not above 70%. A client with an oxygen saturation of only 70% has an increased risk of dying due to complications of poor oxygenation. The pulse oximeter measures the oxygen saturation of the clients hemoglobin. The reported percentage represents the light absorbed by oxygenated and deoxygenated hemoglobin. The sensor may be placed on the clients finger or earlobe. The test is noninvasive and will not cause the client to feel pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 14

Type: MCMA

The nurse is preparing to place the pulse oximeter sensor on the client. The nurse places the pulse oximeter sensor on the earlobes of which of the following clients?

Standard Text: Select all that apply.

1. The clients body mass index is 33.

2. The client has been diagnosed with an evolving myocardial infarction.

3. The client is wearing dark nail polish.

4. The client is 82 years old.

5. The client has thickened nails.

Correct Answer: 1,2,3,5

Rationale 1: The clients body mass index is 33. The client who has a body mass index of 33 is considered to be obese. The nurse should place the pulse oximeter sensor on this clients earlobe.

Rationale 2: The client has been diagnosed with an evolving myocardial infarction. The nurse should place the pulse oximeter sensor on the earlobe of a client with a vascular disease.

Rationale 3: The client is wearing dark nail polish. The nurse will not be able to get an accurate reading of the clients oxygen saturation level if the client is wearing dark nail polish. The nurse should place the pulse oximeter sensor on the earlobe of this client.

Rationale 4: The client is 82-years-old. The nurse does not necessarily need to place the pulse oximeter sensor on the client who is older.

Rationale 5: The client has thickened nails. The nurse will not be able to get an accurate reading of the clients oxygen saturation level if the client has thickened nails. The nurse should place the pulse oximeter sensor on the earlobe of this client.

Global Rationale: The client who has a body mass index of 33 is considered to be obese. The nurse should place the pulse oximeter sensor on this clients earlobe because this is the best way to gain information about an obese clients oxygen saturation level. The nurse should place the pulse oximeter sensor on the earlobe of a client with a vascular disease. The nurse will not be able to get an accurate reading of the clients oxygen saturation level if the client is wearing dark nail polish. The nurse should place the pulse oximeter sensor on the earlobe of this client. The nurse will not be able to get an accurate reading of the clients oxygen saturation level if the client has thickened nails. The nurse should place the pulse oximeter sensor on the earlobe of this client. The nurse does not necessarily need to place the pulse oximeter sensor on the client who is older.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 15

Type: MCSA

The student nurse is preparing to auscultate the clients lungs during the initial assessment. The student nurse is being assisted by the experienced nurse. Which of the following statements by the student nurse indicate the need for further education?

1. I should think about how loud the auscultated sound is, the tone of the sound, and how long it lasts.

2. I should leave the clients television on during the assessment to make the client feel relaxed and comfortable during the assessment.

3. I have to remember to keep the client warm during this part of the assessment.

4. I cannot listen through the clients gown.

Correct Answer: 2

Rationale 1: The student nurse should note the intensity, pitch, and duration of the auscultated sound. Auscultating body sounds requires a quiet environment in which the nurse can listen not just for the presence or absence of sounds, but also for the characteristics of each sound.

Rationale 2: External distractions such as radios, televisions, and loud equipment should be eliminated whenever possible.

Rationale 3: The student nurse should ensure that the client remains warm during this part of the assessment because shivering can impair the nurses ability to hear the sound well. The nurse cannot listen through gowns or drapes.

Rationale 4: The student nurse should place the stethoscope firmly over the area to be auscultated.

Global Rationale: Auscultating body sounds requires a quiet environment in which the nurse can listen not just for the presence or absence of sounds, but also for the characteristics of each sound. External distractions such as radios, televisions, and loud equipment should be eliminated whenever possible. The student nurse should note the intensity, pitch, and duration of the auscultated sound. The student nurse should ensure that the client remains warm during this part of the assessment because shivering can impair the nurses ability to hear the sound well. The nurse cannot listen through gowns or drapes. The student nurse should place the stethoscope firmly over the area to be auscultated.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 16

Type: FIB

The hospitalized client has an indwelling urinary catheter. The client has had 230 milliliters of urine collect in the drainage bag over the last 8 hours. How many milliliters of urine is the client producing on average each hour? Round to the nearest whole number.
_______ milliliters per hour

Standard Text:

Correct Answer: 29 milliliters per hour

Rationale: The client has produced 230 milliliters of urine over the last 8 hours. 230 divided by 8 is 28.75. When rounded to the nearest whole number, it is 29 milliliters per hour.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client

Question 17

Type: FIB

The hospitalized clients healthcare provider writes an order for the client to receive 1000 milliliters of normal saline over 7 hours. How many milliliters per hour should the nurse set the IV pump for? Round the answer to the nearest whole number.
_____ milliliters per hour

Standard Text:

Correct Answer: 143 milliliters per hour

Rationale: 1000 milliliters divided by 7 hours is 142.85714 milliliters per hour. When rounded to the nearest whole number, the answer is 143 milliliters per hour.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.3: Apply knowledge and skills in assessment of a hospitalized client.

Question 18

Type: SEQ

The nurse has assessed the hospitalized client. The nurse is preparing to document the findings using APIE. Rank the following findings in the proper order of documentation.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The client states upon admission, I dont know whats wrong with me, but I cant see out of my left eye and I cant stand up by myself.

Choice 2. The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance.

Choice 3. The healthcare provider writes an order for the nurse to administer heparin.

Choice 4. On the morning of the clients discharge from the hospital, the client has been able to ambulate 50 feet with a walker.

Correct Answer: 2,3,4,1

Rationale 1: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. When using this method, documentation of assessment includes combining the subjective and objective data.

Rationale 2: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. The nurse will draw conclusions from the data, identify and record the problem or problems, and plan to address these problems.

Rationale 3: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. Interventions are documented as they are carried out.

Rationale 4: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. Evaluation refers to documentation of the response to the plan.

Global Rationale: The letters APIE refer to Assessment, Problem, Intervention, and Evaluation. When using this method, documentation of assessment includes combining the subjective and objective data. The nurse will draw conclusions from the data, identify and record the problem or problems, and plan to address these problems. Interventions are documented as they are carried out. Evaluation refers to documentation of the response to the plan.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 29.4: Document findings from assessment of the hospitalized client.

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