Detailed Answer Key Final Health Assessment - Final Study Guide Key

1. An assistive personnel (AP) 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? A. BP Rationale: A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions. B. Respiratory rate Rationale: This respiratory rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. C. Pulse rate Rationale: This pulse rate is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. D. Temperature Rationale: This temperature reading is within the expected reference range. Unless it deviates markedly from the client’s usual readings, the nurse need not take any action at this time. 2. A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client’s medical record? A. "There were no injuries sustained." Rationale: The nurse should document the facts, which includes objective and subjective data and not make suppositions about whether injuries were sustained. B. "An incident report was completed." Rationale: Documenting that an incident report was completed is not appropriate for the nurse to include in the chart. C. "An incident report was forwarded to risk management." Rationale: Documenting that an incident report was forwarded to risk management is not appropriate for the nurse to include in the chart. D. "The provider was notified." Rationale: Nursing interventions that support factual information should be documented in the health record. 3. A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears Rationale: The nurse should check less pigmented areas, such as the lips and tongue, not the external ear, for cyanosis in clients who have dark skin. B. Dorsal surface of the hand Rationale: The nurse should check the palmar surface (the palms) of the hands when assessing for cyanosis in clients who have dark skin. C. Conjunctivae Rationale: To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes. D. Dorsal surface of the foot Rationale: The nurse should check the plantar surface (the soles) of the feet when assessing for cyanosis in clients who have dark skin. 4. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? A. Determining the client’s length of stay Rationale: Indirect nursing care activities center on managing the environment and collaboration with the interprofessional health care team. This does not include determining the client’s length of stay, which is the responsibility of the provider. B. Assigning tasks to an assistive personnel (AP) Rationale: Delegation of nursing care to an AP is considered indirect care. To meet the clients’ needs, activities of daily living such as ambulation, bathing and vital signs may be assigned to an AP, but the nurse is responsible for verifying that the tasks have been completed according to standards of care. C. Providing anticipatory guidance to a client in crisis Rationale: Counseling is considered a direct care action by nurses when helping a client manage stress and facilitate problem solving. D. Establishing the client’s secondary medical diagnoses Rationale: Indirect nursing care activities center on managing the environment and collaboration with the interprofessional health care team. This does not include determining the client’s secondary medical diagnoses, which is the responsibility of the provider. 5. A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client’s infection? A. Changing the client’s bed linens each day Rationale: While changing linens helps maintain a clean environment, it does not stop the transmission of infection. B. Encouraging the client to consume a high-protein diet Rationale: A diet high in protein can help the client fight the infection, but it does not prevent its transmission. C. Performing hand hygiene before, during, and after direct contact with the client Rationale: The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures. D. Placing the client in a room with positive-pressure airflow Rationale: Placing the client in a positive pressure airflow room will not prevent the transmission of infection. Positive-pressure airflow keeps pathogens from entering the client’s room. This is a strategy for clients who have immune-system compromise.