A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states they were busy and did not have a chance to tell the nur...
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900.
The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood
pressure was low when it was taken at 0830. The NAP states they were busy and did not have
a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed.
The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing
process did the nurse first make an error?
Diagnosis
Evaluation
Implementation
Assessment - ANS Assessment
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The
nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The
prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked
with the client 40 min later, when the client reported improvement. The newly licensed nurse left
out which of the following steps of the nursing process?
Intervention
Evaluation
Planning
Assessment - ANS Assessment
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing
diagnoses. Which nursing diagnosis is the highest priority for this patient?
Risk for impaired skin integrity
Risk for infection
,Spiritual distress
Reflex urinary incontinence - ANS Reflex urinary incontinence
While completing an admission database, the nurse is interviewing a patient who states "I am
allergic to latex." Which action will the nurse take first?
Immediately place patient in isolation
Ask the patient to describe the type of reaction
Document latex allergy on medication administration record
Process to the termination phase of interview - ANS Ask the patient to describe type of
reaction
A nurse is planning care for a client who is postoperative. Which of the following statements
about pain management should the nurse consider when implementing client care? (Select all
that apply.)
All clients will express the feeling of pain both verbally and nonverbally.
Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
Use of analgesics will eventually lead to addiction.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized. - ANS
Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized.
The nurse is caring for an African American patient with COPD. The nurse knows that the best
location to assess for hypoxia is the:
Lower extremities
Abdomen
Earlobes
, Oral mucosa - ANS Oral mucosa
What is the most appropriate way to assess the pain of a patient who is oriented and has
recently had surgery?
Observe cardiac monitor for increased HR
Ask patient describe the effect of pain on ability to cope
Ask patient to rate level of pain
Assess patients body language - ANS Ask patient to rate level of pain
An assistive personnel reports a client's vital signs as tympanic temperature 37.1° C (98.8° F),
pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs
should the nurse re-measure?
BP
Temp
Pulse Rate
Respiratory Rate - ANS BP
In which order will the nurse use the nursing process steps during the clinical decision-making
process?
1. Evaluating goals
2. Assessing patient needs
3. Planning priorities of care
4. Determining nursing diagnoses
5. Implementing nursing interventions - ANS Assess, Determine diagnosis, Plan priorities
of care, Implement interventions, Evaluate goals
During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated
over the carotid artery. The nurse notifies the medical provider of the unexpected physical
finding known as:
Clubbing
Bruit
Murmur
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