Which of the following forms of subjective client data would be documented in the medical record by the nurse? A- client's face is pale B- cervical lymph nodes are palpable C- nursing assistant reports client refused lunch D- client feels nauseated d This is the only subjective choice
Priorities a...
NUR 225 Exam 1 Practice Questions and
Solutions
Which of the following forms of subjective client data would be documented in the
medical record by the nurse?
A- client's face is pale
B- cervical lymph nodes are palpable
C- nursing assistant reports client refused lunch
D- client feels nauseated ✅d
This is the only subjective choice
Priorities are established to help the nurse anticipate and sequence nursing
interventions when a client has multiple problems or alterations. Priorities are
determined by the client's?
A- physician
B- non-emergent, non life threatening needs
C- future well being
D- urgency of problems ✅d
The rn has received her client assignment for the day shift. After making the initial
rounds and assessing the clients, which client would the rn need to develop a plan of
care for first?
A- a client who is ambulatory
B- a client who has a fever, is diaphoretic and restless
C- a client scheduled for ot @ 1300
D- client who just had an appendectomy and has pain medication ✅b
Restless is not good!
A nurse is caring for a pt who had an asthma attack. 10 min after administering an
inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is
easier. The nurse is engaging in which phase of the nursing process?
A- assessment
B- diagnosis
C- planning
D- implementing
E- evaluation ✅e
The nurse has asked the pt about his current admission and has examined pt. Based on
the info, recognizing cues and patterns in the data, the nurse has identified and
documented the primary concern for nursing care. Which of the following steps in the
nursing process is this an example of?
A- assessment
B- diagnosis
C- planning
, D- implementation
E- evaluation ✅b
Perrla ✅pupils are
Equal
Round
Reactive to
Light (direct and consensual) and
Accommodate
Your patient is being transported to special procedures for picc line placement. The pt is
in droplet precautions. What are your nursing actions to ensure proper pt transport?
A- notify the receiving dept and place a surgical mask on pt
B- place an n95 mask on pt and notify receiving dept
C- cancel transport and notify physician
D- notify receiving dept and place goggle, gown, and mask on pt ✅a
A nurse is conducting an assessment of an american indian women who has come to
the clinic complaining of a headache. Pt tells the nurse that the meds prescribed by the
tribal leader have done some good. What is the appropriate response?
A- tell me about these meds and how often you take them
B- i advise you from taking them
C- could these meds be the cause of your headaches?
D- maybe you should increase the frequency of the healer's meds ✅a
Which patient would be least likely to need restraints?
A_ pt who is up ad lib but refuses meds
B- pt who is physically abusive to staff
C- pt who has pulled out an iv and still has a foley and feeding tube in
D- pt who needs o2 and removes their nasal cannula ✅a
What are the precautions for a mrsa pneumonia pt? ✅droplet
You are observing your pt use the incentive spirometry device. What demonstration by
the patient lets you know the pt understands how to use the device property
A- the pt inhales slowly and maintains the flow indicator evenly
B- the pt blows on the mouthpiece rapidly
C- the pt uses the incentive spirometer once a day
D- the pt rapidly inhales on the device and exhales ✅a
The best method of oxygen administration for a client with copd uses a ✅venturi mask-
can be very specific with o2 %
The nurse is caring for a pt who had back surgery 2 days ago. The pt is hesitant to
move around because of fear of pain. The initial shift assessment reveals diminished
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