Patient Assessment and Documentation > Fundamentals
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Special Considerations in Patient Assessment and Documentation
Total Questions : 6
Showing 6 questions, Sign in for moreA nurse is assessing a client who has a history of substance abuse.
Which of the following findings should the nurse report to the provider immediately?
Explanation
Respiratory depression
Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.
Incorrect options:
A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.
C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.
A nurse is caring for a client who has a tracheostomy tube and requires suctioning.
Which of the following actions should the nurse take to prevent hypoxia during the procedure?
Explanation
All of the above
Rationale: The nurse should apply suction for no longer than 10 seconds at a time, preoxygenate the client with 100% oxygen before suctioning, and limit the number of suction passes to three per session to prevent hypoxia during tracheostomy suctioning. These actions help to minimize the interruption of oxygen delivery and reduce the risk of mucosal trauma and bleeding.
Incorrect options:
None
A nurse is performing a skin assessment on a client who has dark skin.
Which of the following techniques should the nurse use to detect cyanosis in this client?
Explanation
Inspect the nail beds and lips for a bluish hue.
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.
Incorrect options:
B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.
C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.
D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.
A nurse is documenting the findings of a physical examination on a client who has heart failure.
Which of the following terms should the nurse use to describe crackles heard in the lungs?
Explanation
Rales
Rationale: Rales are fine, high-pitched crackling sounds heard in the lungs due to fluid accumulation or inflammation. They are commonly heard in clients who have heart failure, pneumonia, or pulmonary edema.
Incorrect options:
A) Wheezes - Wheezes are high-pitched musical sounds heard in the lungs due to narrowed airways. They are commonly heard in clients who have asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
B) Rhonchi - Rhonchi are low-pitched snoring sounds heard in the lungs due to secretions or mucus in the large airways. They are commonly heard in clients who have bronchitis, cystic fibrosis, or pneumonia.
D) Stridor - Stridor is a high-pitched crowing sound heard in the upper airway due to obstruction or inflammation. It is commonly heard in clients who have croup, epiglottitis, or foreign body aspiration.
A nurse is reviewing the laboratory results of a client who has diabetes mellitus.
Which of the following values should the nurse report to the provider as a priority?
Explanation
Urine ketones 3+
Rationale: Urine ketones 3+ indicate a high level of ketones in the urine, which is a sign of diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. DKA occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the production of acidic ketones that cause metabolic acidosis. The nurse should report this value to the provider as a priority and prepare to administer intravenous fluids, insulin, and electrolytes as prescribed.
Incorrect options:
A) Hemoglobin A1c 8.5% - Hemoglobin A1c is a measure of the average blood glucose level over the past 2 to 3 months. A value of 8.5% indicates poor glycemic control and an increased risk of complications, but it is not an emergency.
B) Blood glucose 180 mg/dL - Blood glucose is a measure of the amount of glucose in the blood at a given time. A value of 180 mg/dL indicates hyperglycemia, which is common in clients who have diabetes mellitus, but it is not an emergency.
D) Serum creatinine 1.2 mg/dL - Serum creatinine is a measure of the amount of creatinine, a waste product of muscle metabolism, in the blood. A value of 1.2 mg/dL is within the normal range for adults and does not indicate any problem.
A nurse is obtaining informed consent from a client who is scheduled for a colonoscopy.
Which of the following statements by the client indicates a need for further clarification?
Explanation
"I think that I can drive myself home after the procedure."
Rationale: The client should be informed that they cannot drive themselves home after the procedure, as they will be under the influence of sedation and may experience drowsiness, impaired judgment, and delayed reaction time. The client should arrange for a responsible adult to accompany them home and stay with them until the effects of sedation wear off.
Incorrect options:
A) "I understand that I will be sedated during the procedure." - This is a correct statement, as sedation is usually administered during a colonoscopy to reduce discomfort and anxiety.
B) "I know that I have to drink a lot of clear liquids before the procedure." - This is a correct statement, as drinking clear liquids before the procedure helps to cleanse the bowel and improve visualization.
C) "I expect that I will have some abdominal cramps and gas after the procedure." - This is a correct statement, as abdominal cramps and gas are common after a colonoscopy due to air insufflation during the procedure. The client should be advised to ambulate and pass gas as tolerated to relieve these symptoms.
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