Which assessment by the nurse most likely indicates that a patient is having difficulty breathing?
a. 18 breaths per minute and inhaled through the mouth
b. 20 breathes per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy
d. 28 breaths per minute and noisy
Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer.
b. Position the patient on the left side.
c. Use an electronic thermometer.
d. Lubricate the thermometer.
d. Lubricate the thermometer.
A nurse is assessing a patient'sideal body weight. Which significant factor should be takin into
consideration when performing this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preferences
b. Body height
A nurse asks a patient's wife specific questions about the patient's health status before admission.
When collecting this information, the nurse is seeking information from a:
a. Primary source
b. Tertiary sources
c. Subjective source
d. Secondary source
, d. Secondary source
A nurse is preforming a physical assessment of a newly admitted patient. Which patient statement
communicates subjective data?
a. "I have sores between my toes."
b. "I dye my hair but it isreally gray."
c. "My joints hurt when I get up in the morning."
d. "My left leg drags on the floor when I am walking."
c. "My joints hurt when I get up in the morning."
A nurse takes a patient's blood pressure and records a diastolic pressure of 120 mm Hg. Which
should the nurse do first?
a. Notify the primary health-care provider.
b. Retake the blood pressure.
c. Notify the nurse in charge.
d. Take the other vitalsigns
b. Retake the blood pressure.
A patient who experienced a stroke has left-sided hemiparesis and is incontinent of urine. Which is
an appropriately worded nursing diagnosis for this patient?
a. The patient has a need to maintain skin integrity.
b. The patient has a stroked evidenced by hemiparesis and incontinence.
c. The patient will be clean and dry and will receive range-of-motion exercises every four hours.
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence
a. 18 breaths per minute and inhaled through the mouth
b. 20 breathes per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy
d. 28 breaths per minute and noisy
Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer.
b. Position the patient on the left side.
c. Use an electronic thermometer.
d. Lubricate the thermometer.
d. Lubricate the thermometer.
A nurse is assessing a patient'sideal body weight. Which significant factor should be takin into
consideration when performing this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preferences
b. Body height
A nurse asks a patient's wife specific questions about the patient's health status before admission.
When collecting this information, the nurse is seeking information from a:
a. Primary source
b. Tertiary sources
c. Subjective source
d. Secondary source
, d. Secondary source
A nurse is preforming a physical assessment of a newly admitted patient. Which patient statement
communicates subjective data?
a. "I have sores between my toes."
b. "I dye my hair but it isreally gray."
c. "My joints hurt when I get up in the morning."
d. "My left leg drags on the floor when I am walking."
c. "My joints hurt when I get up in the morning."
A nurse takes a patient's blood pressure and records a diastolic pressure of 120 mm Hg. Which
should the nurse do first?
a. Notify the primary health-care provider.
b. Retake the blood pressure.
c. Notify the nurse in charge.
d. Take the other vitalsigns
b. Retake the blood pressure.
A patient who experienced a stroke has left-sided hemiparesis and is incontinent of urine. Which is
an appropriately worded nursing diagnosis for this patient?
a. The patient has a need to maintain skin integrity.
b. The patient has a stroked evidenced by hemiparesis and incontinence.
c. The patient will be clean and dry and will receive range-of-motion exercises every four hours.
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence
