Patient Assessment and Documentation > Fundamentals
Exam Review
The Assessment Patient Process
Total Questions : 6
Showing 6 questions, Sign in for moreA nurse is assessing a client who is in the first stage of labor.
Which finding should the nurse report to the provider immediately?
Explanation
The client's fetal heart rate is 180 beats per minute.
Rationale: A fetal heart rate of 180 beats per minute is above the normal range of 110 to 160 beats per minute and indicates fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions to improve fetal oxygenation, such as changing the client's position, administering oxygen, or initiating a fluid bolus.
Incorrect options:
A) The client's cervix is dilated to 4 cm. - This is a normal finding for the first stage of labor, which lasts until the cervix is fully dilated to 10 cm.
C) The client's contractions are 5 minutes apart. - This is a normal finding for the active phase of the first stage of labor, which occurs when the contractions are 3 to 5 minutes apart and last for 40 to 60 seconds.
D) The client's amniotic fluid is clear and odorless. - This is a normal finding that indicates the absence of infection or meconium staining in the amniotic fluid.
A nurse is caring for a client who has a chest tube connected to a water seal drainage system.
Which action should the nurse take to ensure proper functioning of the system?
Explanation
Keep the drainage system below the level of the client's chest.
Rationale: Keeping the drainage system below the level of the client's chest prevents backflow of fluid into the pleural space and maintains negative pressure in the system.
Incorrect options:
A) Clamp the chest tube periodically to check for air leaks. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.
C) Empty the drainage chamber when it is half full. - This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.
D) Add sterile water to the suction control chamber as needed. - This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.
A nurse is reviewing laboratory results for a client who has diabetic ketoacidosis (DKA).
Which finding should alert the nurse to a potential complication of DKA?
Explanation
Serum potassium level of 6.5 mEq/L
Rationale: A serum potassium level of 6.5 mEq/L indicates hyperkalemia, which is a potential complication of DKA due to insulin deficiency, acidosis, and dehydration. Hyperkalemia can cause cardiac dysrhythmias, muscle weakness, and paresthesia.
Incorrect options:
A) Blood glucose level of 350 mg/dL - This is an expected finding for a client who has DKA, as insulin deficiency leads to hyperglycemia and glycosuria. The goal of treatment for DKA is to lower blood glucose levels gradually to prevent cerebral edema.
C) Arterial blood pH of 7.25 - This is an expected finding for a client who has DKA, as insulin deficiency leads to increased breakdown of fatty acids and production of ketones, resulting in metabolic acidosis. The normal range for arterial blood pH is 7.35 to 7.45.
D) Serum bicarbonate level of 18 mEq/L - This is an expected finding for a client who has DKA, as metabolic acidosis causes a decrease in serum bicarbonate levels due to buffering mechanisms. The normal range for serum bicarbonate levels is 22 to 26 mEq/L.
A nurse is planning care for a client who has a new diagnosis of tuberculosis (TB).
Which intervention should the nurse include in the plan of care?
Explanation
Place the client in a negative pressure isolation room.
Rationale: Placing the client in a negative pressure isolation room is an intervention that prevents the transmission of TB to other clients and staff. Negative pressure rooms have ventilation systems that create a lower pressure inside the room than outside, causing air to flow into the room and preventing air from escaping.
Incorrect options:
B) Administer a single antitubercular medication daily. - This is an incorrect intervention, as TB requires combination therapy with multiple antitubercular medications to prevent drug resistance and ensure effective treatment. The standard regimen for TB consists of four drugs: isoniazid, rifampin, ethambutol, and pyrazinamide.
C) Obtain three consecutive sputum cultures for acid-fast bacilli (AFB). - This is an intervention that is done before the diagnosis of TB is confirmed, not after. Sputum cultures for AFB are used to identify the presence of Mycobacterium tuberculosis, the causative agent of TB. Three consecutive negative sputum cultures are required to declare the client noninfectious.
D) Instruct the client to wear a surgical mask when outside the room. - This is an incorrect intervention, as surgical masks do not provide adequate protection against TB. The client should wear a high-efficiency particulate air (HEPA) respirator when outside the room, which filters out 99.97% of airborne particles.
A nurse is evaluating a client who has chronic kidney disease (CKD) and is receiving hemodialysis.
Which finding indicates that the client's nutritional status is improving?
Explanation
The client's serum albumin level is 4.0 g/dL.
Rationale: A serum albumin level of 4.0 g/dL indicates that the client's nutritional status is improving, as albumin is a protein that reflects the client's protein intake and nutritional status. The normal range for serum albumin levels is 3.5 to 5.0 g/dL.
Incorrect options:
B) The client's blood urea nitrogen (BUN) level is 60 mg/dL. - This finding indicates that the client's nutritional status is worsening, as BUN is a waste product of protein metabolism that accumulates in the blood due to impaired renal function. A high BUN level can indicate excessive protein intake or inadequate dialysis. The normal range for BUN levels is 10 to 20 mg/dL.
C) The client's body weight is 2 kg higher than the dry weight. - This finding indicates that the client has fluid retention, not improved nutritional status. Dry weight is the weight of the client after dialysis, when all excess fluid has been removed. A weight gain of more than 1 kg above the dry weight can indicate inadequate fluid restriction or dialysis.
D) The client's serum creatinine level is 3.0 mg/dL. - This finding indicates that the client has impaired renal function, not improved nutritional status. Creatinine is a waste product of muscle metabolism that accumulates in the blood due to reduced glomerular filtration rate (GFR). A high creatinine level can indicate decreased muscle mass or inadequate dialysis. The normal range for serum creatinine levels is 0.6 to 1.2 mg/dL.
A nurse is teaching a client who has hypertension about lifestyle modifications to lower blood pressure.
Which statement by the client indicates an understanding of the teaching?
Explanation
"I will quit smoking as soon as possible."
Rationale: Quitting smoking is a lifestyle modification that can lower blood pressure, as smoking causes vasoconstriction and increases cardiac workload and oxygen demand.
Incorrect options:
A) "I will limit my sodium intake to 4 grams per day." - This statement indicates a need for further teaching, as limiting sodium intake to 4 grams per day is not sufficient for someone with hypertension. The recommended daily sodium intake for individuals with hypertension is generally lower, around 1,500-2,300 milligrams (mg).
B) "I will drink no more than two cups of coffee per day." - While limiting caffeine intake is generally recommended for individuals with hypertension, this statement does not address other lifestyle modifications specifically related to blood pressure.
C) "I will exercise for at least 30 minutes three times per week." - Regular exercise is beneficial for overall health, but the frequency and duration mentioned in this statement may not be sufficient for effectively lowering blood pressure. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week for individuals with hypertension.
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