NR222 EDAPT The Nursing Process Exam Elaboration |100% Correct Answers|
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Course
Nur 222
Institution
Nur 222
NR222 EDAPT The Nursing Process
Exam Elaboration |100% Correct
Answers|
A nurse assesses a 42-year-old client at a health clinic. The client is married and lives in a condo with
their spouse. The client reports having frequent voiding and pain when they pass urine. The nurse asks
whether ...
NR222 EDAPT The Nursing Process
Exam Elaboration |100% Correct
Answers|
A nurse assesses a 42-year-old client at a health clinic. The client is married and lives in a condo with
their spouse. The client reports having frequent voiding and pain when they pass urine. The nurse asks
whether the client has to go to the bathroom frequently during the night and they respond, "Yes, usually
twice or more." The client had an episode of diarrhea one week ago. They weigh 136 kilograms and
report having difficulty cleansing their perineum after voiding or passing stool.
Which data finding(s) indicates the nursing diagnosis of impaired urinary elimination? Select all that
apply.
Weight
Age 42 years
Episode of diarrhea
Painful urination
Frequent urination at night *Ans* Painful urination
frequent urination at night
A nurse on a surgical unit is caring for a client who had surgery yesterday to repair a broken leg. The
client is restless, grimacing, and groaning. The client's heart rate and blood pressure are elevated. The
nurse notices that the client's pain medication has not yet been administered this morning. What part of
this situation should the nurse reflect upon? *Ans* The delay in administration of the pain
medication
Based on the nursing diagnosis of impaired gas exchange, which intervention is most appropriate for the
client? *Ans* Initiate supplemental oxygen
Click to specify the assessment findings that indicate the client's condition is improving or declining.
1. Respiratory rate 22 per minute
2. Oxygen saturation 82%
3. Temperature 99.2°F (37.3°C)
, 4. Client states "I feel like I can breathe better." *Ans* 1. Improving
2. Declining
3. Improving
4. Improving
For each nursing intervention, identify if the intervention is a direct or indirect care measure.
1. Initiating an intravenous line to provide hydration
2. Repositioning the client every 2 hours to prevent pressure injuries
3. Placing a sign on the door indicating the need for a mask when entering the client's room
4. Clearing the walkway to the bathroom so the client does not fall
5. Assessing the client's vital signs after administering blood pressure medication
6. Inserting a nasogastric tube to decompress the client's stomach *Ans* 1. Direct Care
2. Direct Care
3. Indirect Care
4. Indirect Care
5. Direct Care
6. Direct Care
In the following scenario, click to select all the components that qualify as objective assessment data.
The nurse is caring for a 48-year-old client who states, "I feel like I can't breathe." Vital signs are
respiratory rate 28 breaths per minute, heart rate 115 beats per minute, and blood pressure 152/95
mmHg. The client grabs their chest and says, "My chest hurts so bad, please help!" The client is sweating
and pale.
The nurse asks the client to rate the pain on a scale from 0-10. The client replies, "10, it hurts so badly!"
The nurse asks the client to describe what the pain feels like and the client reports that their pain feels
like pressure. *Ans* Respiratory rate 28 breaths per minute
Heart rate 115 beats per minute
Blood pressure 152/95 mmHg
Sweating/pale
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