questions (VERIFIED ANSWERS) |ALREADY
GRADED A+- answers at end.
• Which assessment by the nurse most likely indicates that a patient is having difficulty
breathing?
• 18 breaths per minute and inhaled through the mouth
• 20 breathes per minute and shallow in character
• 16 breaths per minute and deep in character
• 28 breaths per minute and noisy
• Which should a nurse always do when taking a rectal temperature?
• Allow self-insertion of the thermometer.
• Position the patient on the left side.
• Use an electronic thermometer.
• Lubricate the thermometer.
• A nurse is assessing a patient’s ideal body weight. Which significant factor should be
takin intoconsideration when performing this assessment?
• Daily intake
• Body height
• Clothing size
• Food preferences
• 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:
• Primary source
• Tertiary sources
• Subjective source
• Secondary source
,• A nurse is preforming a physical assessment of a newly admitted patient. Which
patient statementcommunicates subjective data?
• “I have sores between my toes.”
• “I dye my hair but it is really gray.”
• “My joints hurt when I get up in the morning.”
• “My left leg drags on the floor when I am walking.”
• A nurse takes a patient’s blood pressure and records a diastolic pressure of 120 mm
Hg. Which shouldthe nurse do first?
• Notify the primary health-care provider.
• Retake the blood pressure.
• Notify the nurse in charge.
• Take the other vital signs.
• A patient had a stroke that resulted in paralysis of the right side. When clustering
data, the nurse grouped the following together: drooling of saliva and slurred speech. Which
information is mostsignificant to include with this clustered data?
• Receptive aphasia
• Inability to ambulate
• Difficulty swallowing
• Incontinence of bowel movements
• A patient who experienced a stroke has left-sided hemiparesis and is incontinent of
urine. Which is anappropriately worded nursing diagnosis for this patient?
• The patient has a need to maintain skin integrity.
• The patient has a stroked evidenced by hemiparesis and incontinence.
• The patient will be clean and dry and will receive range-of-motion exercises every
four hours.
• The patient is at risk for impaired skin integrity related to left-sided hemiparesis and
incontinence.
• A nurse uses the interviewing process of clarification when interviewing a patient.
Which is the nursedoing when this communication technique is used?
• Paraphrasing the patient’s message
, • Restating what the patient has said
• Reviewing the patient’s communication
• Verifying what is implied by the patient
• A patient has dependent edema of the ankles and feet and is obese. Which diet
should the nurseexpect the primary health-care provider to order?
• Low in sodium and high in fat
• Low in sodium and low in calories
• High in sodium and high in protein
• High in sodium and low in carbohydrates
• A patient who is undergoing cancer chemotherapy says to the nurse, “This is no way
to live.” Whichresponse uses reflective techniques?
• “Tell me more about what you are thinking.”
• “You sound discouraged today.”
• “Life is not worth living?”
• “What are you saying?”
• A nurse is assessing a patient who reports being incontinent. Which question should
the nurse ask toelicit information related to urge incontinence?
• “Does urination occur immediately after coughing?”
• “Do you urinate small amounts of urine frequently?”
• “Do you begin urinating immediately after feeling the need to urinate?”
• “Does urination occur at predictable intervals without feeling the need to urinate?”
• Which is the most common reason why older adults become incontinent of urine?
• They use incontinence to manipulate others.
• The muscles that control urination become weak.
• They tend to drink less fluid than younger patients.
• Their increase in weight places pressure on the bladder.
• What is the nurse doing when formulating a nursing diagnosis?
• Planning