NURS217: Health Assessment in Nursing / Fundamentals
questions with correct answers
A nurse in an emergency department is caring for a client.
Physical Examination
1200:
Influenza with nausea, vomiting, and diarrhea for 3 days. Client is
tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous
membranes, poor turgor, and oliguria.
Plan: Admit for IV fluids.
Vital Signs
1200:Temperature 38.4° C (101.1° F)
Heart rate 126/min
Respiratory rate 28/min
BP 92/54 mm Hg
Oxygen saturation 93%
Nurses' Notes
1900:
Client is disoriented, confused. Client attempting to get out of bed
without assistance and states, "I'm going home." Returned to bed,
attempted to reorient to time, place, and circumstances. Call placed to
client's family, no answer, message left.
,1915:
Client remains disoriented. Attempting to pull out IV line. Call was
returned by client's family. Updated them on situation.
Complete the following sentence by using the list of options. Correct
Answer.-The nurse should first review medications that might cause
confusion, followed by using other methods to keep the client safe.
A nurse in a provider's clinic is caring for a client who has heart failure.
Nurses' Notes
First Clinic Visit:
Client arrives to clinic with report of increasing shortness of breath,
fatigue, and weakness. States they get short of breath with minimal
activity. Client is alert and oriented to person, place, and time. Moves all
extremities well, follows simple commands. Sinus tachycardia...
A nurse is evaluating teaching for a client who has heart failure. Which
of the following 3 statements by the client indicates an understanding of
the teaching?
"I have been weighing myself every other morning."
"I am trying to decrease my intake of foods with potassium."
"I am limiting my sodium intake to 2 grams daily."
"I am eating fewer potato chips and more fruit for snacks."
,"I lie down and rest after meals."
"I know to call my doctor if I gain 3 pounds or more in 2 days." Correct
Answer.-"I am limiting my sodium intake to 2 grams daily."
"I am eating fewer potato chips and more fruit for snacks."
"I know to call my doctor if I gain 3 pounds or more in 2 days."
A nurse is caring for a client who is postoperative following abdominal
surgery.
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client drowsy
but responds to verbal stimuli. Client is oriented to person, place, and
time. Client can move all extremities. Hypoactive bowel sounds.
Abdominal dressing intact with drainage noted and marked. Indwelling
urinary catheter in place and draining yellow urine. Infusing lactated
Ringer's at 100 mL/hr to the right forearm. Client positioned for
comfort, side rails raised x 2, call light in the client's reach.
Click to highlight the assessment findings below that the nurse should
report to the provider. To deselect a finding, click on the finding again.
Neurological assessment
Incisional drainage
, Urinary output
Reported pain level
Gastrointestinal assessment
Vital signs Correct Answer.-Urinary output
Reported pain level
Vital signs
A nurse is caring for a client in a medical-surgical unit.
Nurses' Notes
0800:
Client is 1 day postoperative following a right knee replacement. Alert
and oriented x4. Sequential compression devices in place. Surgical
dressing dry and intact. Pedal pulses +2 bilaterally. Client rates pain as
an 8 on a scale of 0 to 10...
After reviewing the assessment findings, which of the following actions
should the nurse plan to take?
Select the 3 actions that the nurse should plan to take.
Assist the client to dangle their legs at the bedside prior to standing.
Encourage the client to bear down when moving up in bed.
Teach the client to shift their weight every hour when sitting.
Delegate the application of sequential compression devices to assistive
personnel.
questions with correct answers
A nurse in an emergency department is caring for a client.
Physical Examination
1200:
Influenza with nausea, vomiting, and diarrhea for 3 days. Client is
tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous
membranes, poor turgor, and oliguria.
Plan: Admit for IV fluids.
Vital Signs
1200:Temperature 38.4° C (101.1° F)
Heart rate 126/min
Respiratory rate 28/min
BP 92/54 mm Hg
Oxygen saturation 93%
Nurses' Notes
1900:
Client is disoriented, confused. Client attempting to get out of bed
without assistance and states, "I'm going home." Returned to bed,
attempted to reorient to time, place, and circumstances. Call placed to
client's family, no answer, message left.
,1915:
Client remains disoriented. Attempting to pull out IV line. Call was
returned by client's family. Updated them on situation.
Complete the following sentence by using the list of options. Correct
Answer.-The nurse should first review medications that might cause
confusion, followed by using other methods to keep the client safe.
A nurse in a provider's clinic is caring for a client who has heart failure.
Nurses' Notes
First Clinic Visit:
Client arrives to clinic with report of increasing shortness of breath,
fatigue, and weakness. States they get short of breath with minimal
activity. Client is alert and oriented to person, place, and time. Moves all
extremities well, follows simple commands. Sinus tachycardia...
A nurse is evaluating teaching for a client who has heart failure. Which
of the following 3 statements by the client indicates an understanding of
the teaching?
"I have been weighing myself every other morning."
"I am trying to decrease my intake of foods with potassium."
"I am limiting my sodium intake to 2 grams daily."
"I am eating fewer potato chips and more fruit for snacks."
,"I lie down and rest after meals."
"I know to call my doctor if I gain 3 pounds or more in 2 days." Correct
Answer.-"I am limiting my sodium intake to 2 grams daily."
"I am eating fewer potato chips and more fruit for snacks."
"I know to call my doctor if I gain 3 pounds or more in 2 days."
A nurse is caring for a client who is postoperative following abdominal
surgery.
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client drowsy
but responds to verbal stimuli. Client is oriented to person, place, and
time. Client can move all extremities. Hypoactive bowel sounds.
Abdominal dressing intact with drainage noted and marked. Indwelling
urinary catheter in place and draining yellow urine. Infusing lactated
Ringer's at 100 mL/hr to the right forearm. Client positioned for
comfort, side rails raised x 2, call light in the client's reach.
Click to highlight the assessment findings below that the nurse should
report to the provider. To deselect a finding, click on the finding again.
Neurological assessment
Incisional drainage
, Urinary output
Reported pain level
Gastrointestinal assessment
Vital signs Correct Answer.-Urinary output
Reported pain level
Vital signs
A nurse is caring for a client in a medical-surgical unit.
Nurses' Notes
0800:
Client is 1 day postoperative following a right knee replacement. Alert
and oriented x4. Sequential compression devices in place. Surgical
dressing dry and intact. Pedal pulses +2 bilaterally. Client rates pain as
an 8 on a scale of 0 to 10...
After reviewing the assessment findings, which of the following actions
should the nurse plan to take?
Select the 3 actions that the nurse should plan to take.
Assist the client to dangle their legs at the bedside prior to standing.
Encourage the client to bear down when moving up in bed.
Teach the client to shift their weight every hour when sitting.
Delegate the application of sequential compression devices to assistive
personnel.
