ADPIE NCLEX QUESTIONS and answers 2021/2022 with complete solutions.

Read the following scenario and identify the term for the characteristics of patient data that are numbered below. The nurse is conducting an initial assessment of a 79 year old female patient admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses clinical reasoning to gather the appropriate patient data, (2) first ask the patient about the most important details leading to her diagnosis, (3) collects as much information as possible to understand the patient's health problems, (4) collects the patient data in an organized manner, (5) verifies that the data obtained is pertinent to the patient care plan, and (6) records the data according to agency policy. 1. Purposeful - The nurse identified the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. 2. Prioritized - The nurse gets the most important information first. 3 . Complete - The nurse gathers as much data as possible to understand the patient health problem and develop a plan of care. 4. Systematic - The nurse gathers the information in an organized manner. 5. Factual & Accurate - The nurse verifies that the information is reliable. 6. Recorded in a standard manner - The nurse records the data according to agency policy so that all caregivers can easily access what is learned. The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. comprehensive b. initial c. time-lapsed d. quick priority d 00:03 01:46 The nurse is admitting a 35 year old pregnant women to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statement best explains the primary reasons a nursing assessment is performed? select all that apply a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy, I know it must be tiresome, but I will try to make it quick." c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure your responses to the medical exam are consistent and that all you data is accurate." e. "We need to check your health status to see what kind of nursing care you may need." f. "We need to see of you require a referral to a physician or other health professional." aef When you receive the shift report, you learn that you patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a. correct the initial assessment form b. redo the initial assessment and document current findings c. conduct and document an emergency assessment d. perform and document a focused assessment of skin integrity d A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever lens all the questions a nurse must ask to get a good baseline of data. What would be the instructors best reply? a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep" b. "You can make the basic questions part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh each new patient" d. "Don't worry about learning all the questions to ask. Every agency has its own assessment form you must use." b The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply a. a patient tells the nurse that she feels nauseous b. a patients ankles are swollen c. a patient tells the nurse that she is nervous about her test results d. a patient complains of having a rash on her arm that is itchy e. a patient rates his pain as a 7 on a scale of 1 to 10 f. a patient vomits after eating dinner acde When the nurse enters the patients room to begin nursing history, the patients wife is there. What should the nurse do? a. introduce oneself and than the wife for being present b. introduce oneself and asks the wife if she wants to remain c. introduce oneself and ask the wife to leave d. introduce the wife and ask the patient if he would like the wife to stay d A nurse is performing an initial comprehensive assessment of an 84 year old male patient admitted to along term care facility from home. The nurse begins the assessment buy asking the patient How would you describe your health status and well-being?" The nurse also asks the patient "What do you do to keep yourself healthy?" Which model for organizing data is the nurse following? a. Maslows Human Needs b. Gordons functional health patterns c. Human response patterns d. Body systems model b The nurse is surprised to detect an elevated temperature (102) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? a. inform the charge nurse b. inform the surgeon c. validate the finding d. document the finding c A student nurse tells the instructor that the patient is fine and has "no complaints." What would be the instructors best response? a. "You made an inference that she is fine because she has no complaints. How do you validate this?" b. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c. "Sometimes everyone gets lucky. Why don't you try to help another patient?" d. "Maybe you should reassess the patient. She has to have a problem - why else would she be here?" a A registered nurse is writing a diagnosis for a 28 year old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. The nurse uses the nursing interview to collect patient data. b. The nurse analyzes data collected in the nursing assessment c. The nurse develops a plan of care for the patient d. The nurse points out the patients strengths e. The nurse assesses the patients mental status f. The nurse identifies community resources to help the family cope bdf A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complications: sepsis e. Infection related to pneumonia f. Risk for septic shock bcf