Deck 29: Assessment of the Hospitalized Client

Question 1

The nurse has assessed the hospitalized client.The nurse is preparing to document the findings using APIE.Rank the following findings in the proper order of documentation.
1)The client states upon admission,"I don't know what's wrong with me,but I can't see out of my left eye and I can't stand up by myself." Choice
2)The client is unable to move from the bed to the chair without the assistance of two nurses.The client is unable to eat without assistance. Choice
3)The healthcare provider writes an order for the nurse to administer heparin. Choice
4)On the morning of the client's discharge from the hospital,the client has been able to ambulate 50 feet with a walker.

Answer 1

2,3,4,1

Question 2

The hospitalized client's healthcare provider writes an order for the client to receive 1000 milliliters of normal saline over 7 hours.How many milliliters per hour should the nurse set the IV pump for? Round the answer to the nearest whole number.
_____ milliliters per hour

Answer 2

143 milliliters per hour

Question 3

The nurse is performing an initial assessment on the hospitalized client.The nurse is assessing the client's respiratory system.Rank the following steps in the correct sequence.
1)The nurse percusses the client's thorax. Choice
2)The nurse unties the client's gown to better visualize the client's thorax. Choice
3)The nurse warms his stethoscope and listens to the client's lung sounds in each lung field. Choice
4)The nurse gently palpates the client's thorax.

Answer 3

3,1,4,2

Question 4

The nurse is performing a rapid assessment for each of the following clients.Which of the following clients require immediate medical assistance?
1)The client is pale and is breathing in a shallow manner.
2)The client's oxygen saturation level is 74% and is dyspneic.
3)The client is rating his pain at a 3 out of a 10 on a pain scale.
4)The client is unable to follow directions.
5)The nurse determines that the client's level of consciousness is decreasing.

Question 5

The nurse is performing routine assessments on five hospitalized clients.Which of the following clients does the nurse expect to exhibit poor skin turgor?
1)The client had an open appendectomy 2 days ago.
2)The client was admitted with severe nausea and vomiting.
3)The client has lost 16 pounds during the last 30 days.
4)The client has had a high fever during the last four days and was admitted through the Emergency Department last night.
5)The client was admitted this morning with a severe migraine.

Question 6

The nurse works on a medical-surgical unit.Which of the following clients will require a rapid assessment?
1)The client had an open appendectomy 2 days ago and is preparing to be discharged today.
2)The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.
3)The client has just been received from the Post Anesthesia Care Unit.
4)The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.
5)The client begins to complain of difficulty breathing.The client's oxygen saturation level has decreased from 93% on room air this morning to 87%.

Question 7

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes.Which of the following statements by the student nurse indicate that further education is required?
1)"The rapid assessment should last approximately 10 minutes."
2)"I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care."
3)"The rapid assessment will help me establish baseline data about the client."
4)"After I perform the rapid assessments on the clients I've been assigned,I can go back and get more information during my routine assessments."

Question 8

The student nurse has performed a rapid assessment on the diabetic client and is reporting information back to the experienced nurse.The student nurse notes that the client is experiencing emotional stress following his wife's recent death.Which of the following statements by the nurse student nurse regarding the effects of emotional stress indicate the need for further education?
1)"Emotional stress can negatively impact his immune system's ability to function."
2)"He's probably not been eating well recently."
3)"I should not ask about his use of drugs or alcohol at this time."
4)"He may be hyperglycemic."

Question 9

The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route.The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature.Which of the following statements by the student nurse indicate the need for further education?
1)"I will need to turn the client into the prone position."
2)"The probe for a rectal thermometer is usually red."
3)"I should insert the thermometer 1.5 to 4 centimeters into the client's anus."
4)"This is an appropriate way to monitor a client's temperature if they are unable to close the mouth around the oral thermometer."

Question 10

The student nurse is preparing to auscultate the client's lungs during the initial assessment.The student nurse is being assisted by the experienced nurse.Which of the following statements by the student nurse indicate the need for further education?
1)"I should think about how loud the auscultated sound is,the tone of the sound,and how long it lasts."
2)"I should leave the client's television on during the assessment to make the client feel relaxed and comfortable during the assessment."
3)"I have to remember to keep the client warm during this part of the assessment."
4)"I cannot listen through the client's gown."

Question 11

The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital.The nurse is assessing the client's oxygenation level and the presence of jaundice.Which of the following statements by the nurse to the client indicate that the nurse is performing these specific assessments?
1)"I need to look at your eyes."
2)"Please open your mouth for me."
3)"Squeeze my fingers with your hands."
4)"I am going to listen to your belly with my stethoscope."
5)"I need to press on your fingernail."

Question 12

The nurse uses the nursing process to create a plan of care for a hospitalized client.Rank the following activities of the nursing process in the proper order.
1)The nurse educates the client regarding the care of his sternal and leg incisions. Choice
2)The client is admitted to the hospital with chest pain.The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft. Choice
3)The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection. Choice
4)The nurse develops a plan to help prevent some of the known complications associated with surgery.

Question 13

The hospitalized client has an indwelling urinary catheter.The client has had 230 milliliters of urine collect in the drainage bag over the last 8 hours.How many milliliters of urine is the client producing on average each hour? Round to the nearest whole number.
_______ milliliters per hour

Question 14

During the physical assessment of a hospitalized client,the client stated,"I've been under an incredible amount of stress after the healthcare provider diagnosed me with colon cancer 2 days ago." Which of the following findings are associated with increased stress?
1)Apical heart rate is 104 beats per minute.
2)Respiratory rate is 16 breaths per minute.
3)Pupils were equal,dilated,and round.
4)Client is hypoglycemic.
5)Blood pressure is 158/94.

Question 15

The student nurse has measured the client's oxygen saturation level by using a pulse oximeter.The student nurse confers with the experienced nurse.Which of the following statements indicate the student nurse requires further education?
1)"A normal finding is that the client's oxygen saturation level is above 70%."
2)"The pulse oximeter can measure the oxygen saturation of the hemoglobin."
3)"I placed the sensor on the client's finger."
4)"This test is noninvasive and painless."

Question 16

The nurse is preparing to assess the general appearance of the hospitalized client.Which of the following statements by the client are expected if the client is experiencing undernutrition?
1)"It seems like I get catch every bug that comes along.I can't seem to stay well."
2)"This wound that I've had for the last 3 months on my leg won't heal."
3)"I have gained 5 pounds over the last week and my ankles and feet are swollen."
4)"My nails are so brittle."
5)"I know my blood pressure has been up because I've been experiencing headaches in the morning,just like last time."

Question 17

The client is performing an assessment of the hospitalized client.After speaking with the client,the nurse believes that the client is demonstrating altered thought processes.Which of the following statements by the client validate the nurse's conclusion?
1)"When I was little I had 4 cats.Can I wear a dress instead of this hospital gown?"
2)"I wish that my grandmother's daughter would visit me more often."
3)"I have never had so much pain.I just don't feel like speaking with you right now."
4)"My doctor has only been to visit me once during the last three days.I'm starting to feel angry that she hasn't come to see if I'm doing better."
5)"Red squirrels dance on the divine divide."