NR-305:| NR 305 HEALTH ASSESSMENT EXAM 2 QUESTIONS WITH 100% CORRECT ANSWERS| GRADED A+

NR-305:| NR 305 HEALTH ASSESSMENT EXAM 2 QUESTIONS WITH 100% CORRECT ANSWERS| GRADED A+1. The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation ANS: A 2. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation a. Assessment 3. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c. Reports of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed 4. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache Disruption of tissue integrity 5. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing ANS: B 6. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a. Decreased cardiac output related to altered myocardial contractility. b. Patient needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort. ANS: A 7. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database c. Developing nursing diagnoses before completing the database 8. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to go to the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?" a. "Do you feel like you need to go to the bathroom?" 9. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology a. 1,