Nur 356 ATI - nursing process
A nurse is evaluating the outcomes for an outpatient client who has depression . Which
of the following client statements indicates a need for further evaluation?
" I had a great trip to the Smokey Mountains . "
" Going back to work has been okay . "
" I just don't like going to the movies like I used to . "
" I can't wait to have my family together next weekend . " - answer" I just don't like going
to the movies like I used to . "
A nurse is planning care for a client who has acute dysphagia . Which of the following
nursing interventions should be included in the plan of care?
Providing a straw for consumption of liquids
Encouraging larger bites
Placing the client in semi - Fowlers position during meals
Instructing the client to tilt head forward when swallowing . - answerInstructing the client
to tilt head forward when swallowing .
A nurse is assessing a client who is being admitted from the PACU following an
abdominal hysterectomy . Which of the following assessments the nurse's priority ?
Oxygen saturation
Abdominal dressing
Urinary output
Pain level - answerOxygen saturation
ABCs
A nurse is assessing a client who has a fracture of the femur . The nurse obtains vital
signs on admission and again in 2 hours . Which of the following changes in
assessment should indicate to the nurse that the client could be developing a serious
complication ?
Increased respiratory rate from 18 to 44 / min .
Increased oral temperature from 36.6 ° C ( 97.8 ° F ) to 37 ° C ( 98.6 ° F ) .
Increased blood pressure from 112/68 to 120/72 mm Hg .
Increased heart rate from 68 to 72 / min . - answerIncreased respiratory rate from 18 to
44 / min .
A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest
as part of her treatment plan . Which of the following outcomes of this intervention
should the nurse document as a goal for this client ?
A nurse is evaluating the outcomes for an outpatient client who has depression . Which
of the following client statements indicates a need for further evaluation?
" I had a great trip to the Smokey Mountains . "
" Going back to work has been okay . "
" I just don't like going to the movies like I used to . "
" I can't wait to have my family together next weekend . " - answer" I just don't like going
to the movies like I used to . "
A nurse is planning care for a client who has acute dysphagia . Which of the following
nursing interventions should be included in the plan of care?
Providing a straw for consumption of liquids
Encouraging larger bites
Placing the client in semi - Fowlers position during meals
Instructing the client to tilt head forward when swallowing . - answerInstructing the client
to tilt head forward when swallowing .
A nurse is assessing a client who is being admitted from the PACU following an
abdominal hysterectomy . Which of the following assessments the nurse's priority ?
Oxygen saturation
Abdominal dressing
Urinary output
Pain level - answerOxygen saturation
ABCs
A nurse is assessing a client who has a fracture of the femur . The nurse obtains vital
signs on admission and again in 2 hours . Which of the following changes in
assessment should indicate to the nurse that the client could be developing a serious
complication ?
Increased respiratory rate from 18 to 44 / min .
Increased oral temperature from 36.6 ° C ( 97.8 ° F ) to 37 ° C ( 98.6 ° F ) .
Increased blood pressure from 112/68 to 120/72 mm Hg .
Increased heart rate from 68 to 72 / min . - answerIncreased respiratory rate from 18 to
44 / min .
A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest
as part of her treatment plan . Which of the following outcomes of this intervention
should the nurse document as a goal for this client ?
