Patient Assessment and Documentation > Fundamentals
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Nursing roles in Patient assessment and documentation
Total Questions : 6
Showing 6 questions, Sign in for moreA nurse is assessing a client who has been admitted with suspected sepsis.
Which finding should the nurse report to the provider immediately?
Explanation
Blood pressure of 90/60 mmHg
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a sign of septic shock and requires immediate intervention. Hypotension results from vasodilation and fluid loss due to the systemic inflammatory response to infection.
Incorrect options:
A) Temperature of 38.5°C (101.3°F) - This is a sign of fever, which is a common symptom of sepsis, but not as urgent as hypotension.
B) Heart rate of 110 beats per minute - This is a sign of tachycardia, which is a compensatory mechanism to maintain cardiac output in sepsis, but not as urgent as hypotension.
D) Respiratory rate of 22 breaths per minute - This is within the normal range for adults and does not indicate respiratory distress.
A nurse is documenting the findings of a head-to-toe assessment on a client who has been hospitalized for pneumonia.
Which statement by the nurse reflects the appropriate use of objective data?
Explanation
"The client has crackles in the lower lobes bilaterally."
Rationale: Objective data are observable and measurable facts that can be verified by the nurse or another health care provider. Crackles are an abnormal lung sound that can be heard with a stethoscope and indicate fluid accumulation in the alveoli.
Incorrect options:
A) "The client reports feeling short of breath and fatigued." - This is an example of subjective data, which are information that only the client can perceive and describe, such as feelings, sensations, and beliefs.
C) "The client states that he has been coughing up green sputum." - This is also an example of subjective data, as it is based on the client's verbal report.
D) "The client rates his pain as 4 out of 10 on a numeric scale." - This is another example of subjective data, as pain is a personal experience that cannot be directly measured by the nurse.
A nurse is performing a skin assessment on a client who has a history of melanoma.
Which finding should alert the nurse to a possible malignant lesion?
Explanation
A black nodule with an irregular border and asymmetrical shape
Rationale: A black nodule with an irregular border and asymmetrical shape is consistent with the ABCDE criteria for melanoma, which are: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Evolving or changing appearance.
Incorrect options:
A) A brown mole with a smooth border and symmetrical shape - This is a normal finding that does not indicate malignancy.
B) A red macule with a flat surface and well-defined edges - This is likely a benign vascular lesion, such as a cherry angioma or petechiae.
D) A yellow papule with a raised surface and round edges - This is likely a benign sebaceous lesion, such as a sebaceous cyst or milia.
A nurse is reviewing the laboratory results of a client who has been diagnosed with diabetes mellitus.
Which value should the nurse recognize as an indicator of poor glycemic control?
Explanation
Glycosylated hemoglobin (HbA1c) of 8%
Rationale: Glycosylated hemoglobin (HbA1c) reflects the average blood glucose level over the past two to three months. A normal HbA1c level is less than 5.7%, while a level above 6.5% indicates diabetes. A level of 8% or higher indicates poor glycemic control and increased risk of complications.
Incorrect options:
A) Fasting blood glucose of 126 mg/dL - This is a borderline value that may indicate prediabetes, but not necessarily poor glycemic control. A fasting blood glucose of 126 mg/dL or higher on two separate occasions is diagnostic of diabetes.
C) Random blood glucose of 180 mg/dL - This is an elevated value that may indicate hyperglycemia, but not necessarily poor glycemic control. A random blood glucose of 200 mg/dL or higher with symptoms of diabetes is diagnostic of diabetes.
D) Urine ketones of negative - This is a normal finding that indicates the absence of ketones in the urine. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. The presence of ketones in the urine indicates diabetic ketoacidosis, a life-threatening complication of diabetes.
A nurse is conducting a mental status examination on a client who has been admitted for psychiatric evaluation.
Which question should the nurse ask to assess the client's orientation?
Explanation
"What day of the week and month of the year is it?"
Rationale: Orientation is the awareness of one's personal identity, location, and time. Asking the client what day of the week and month of the year it is can help to assess the client's orientation to time.
Incorrect options:
A) "What is your name and date of birth?" - This question can help to assess the client's orientation to person, but not to location or time.
B) "Do you know where you are and why you are here?" - This question can help to assess the client's orientation to place, but not to person or time.
D) "Do you have any thoughts of harming yourself or others?" - This question can help to assess the client's suicidal or homicidal ideation, but not their orientation.
A nurse is preparing to administer an intramuscular injection to a client who has a latex allergy.
Which action should the nurse take to prevent an allergic reaction?
Explanation
Use a non-latex glove to palpate the injection site
Rationale: The nurse should use a non-latex glove to palpate the injection site, as latex gloves can cause skin irritation, rash, or anaphylaxis in clients who have a latex allergy.
Incorrect options:
A) Use a filter needle to draw up the medication from the vial - This action is not related to preventing an allergic reaction, but rather to preventing contamination or injury from glass particles that may be present in some vials.
C) Use an alcohol swab to cleanse the injection site - This action is not related to preventing an allergic reaction, but rather to preventing infection by reducing the number of microorganisms on the skin.
D) Use a Z-track technique to inject the medication - This action is not related to preventing an allergic reaction, but rather to preventing leakage or irritation of the medication into the subcutaneous tissue by creating a zigzag path with the needle.
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