NR 304 Final Exam - The Nursing Process Test Success

While making rounds, the nurse finds a patient on the floor in the hall. Which should be the nurse's initial response? 1. Inspect the patient for injury. 2. Transfer the patient back to bed. 3. Move the patient to the closest chair. 4. Report the patient's condition to the nurse manager. - 1. Inspect the patient for injury. Rationale: An assessment must be made to determine if any intervention is necessary to stabilize an injured body part before moving the patient; moving an injured person can exacerbate an injury. Which should the nurse do to avoid patient accidents? 1. Provide a cane for walking if the patient is weak. 2. Determine the strength of a patient before walking. 3. Apply a vest restraint when a patient is using a wheelchair. 4. Keep the overbed table in front of a patient sitting in a chair. - 2. Determine the strength of a patient before walking. Rationale: Nurses must always assess a patient before having the patient walk to ensure that the patient has the strength to ambulate safely. Which assessment by the nurse most likely indicates that a patient is having difficulty breathing? 1. 18 breaths per minute & inhaled through the mouth 2. 20 breaths per minute & shallow in character 3. 16 breaths per minute & deep in character 4. 28 breaths per minute & noisy - 4. 28 breaths per minute & noisy Rationale: 28 breaths per minute is outside the expected range for an adult; expected respirations should be between 14 & 20, effortless, & noiseless. This patient may be experiencing respiratory distress. Which should a nurse always do when taking a rectal temperature? 1. Allow self-insertion of the thermometer. 2. Position the patient on the left side. 3. Use an electric thermometer. 4. Lubricate the thermometer. - 4. Lubricate the thermometer. Rationale: Lubricating a rectal thermometer is always done to facilitate entry into the rectum; a lubricant reduces resistance when the thermometer is inserted through the anal sphincters. A nurse is assessing a patient's ideal body weight. Which significant factor should be taken into consideration when performing this assessment? 1. Daily intake 2. Body height 3. Clothing size 4. Food preferences - 2. Body height Rationale: To calculate ideal body weight, the nurse must know the patient's height, age, & extent of bone structure.