Exam 29: Assessment of the Hospitalized Client

The nurse works on a medical-surgical unit.Which of the following clients will require a rapid assessment?

The hospitalized client's healthcare provider writes an order for the client to receive 1000 milliliters of normal saline over 7 hours.How many milliliters per hour should the nurse set the IV pump for? Round the answer to the nearest whole number. _____ milliliters per hour

The nurse is preparing to assess the general appearance of the hospitalized client.Which of the following statements by the client are expected if the client is experiencing undernutrition?

The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route.The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature.Which of the following statements by the student nurse indicate the need for further education?

During the physical assessment of a hospitalized client,the client stated,"I've been under an incredible amount of stress after the healthcare provider diagnosed me with colon cancer 2 days ago." Which of the following findings are associated with increased stress?

The nurse is performing routine assessments on five hospitalized clients.Which of the following clients does the nurse expect to exhibit poor skin turgor?

The student nurse has performed a rapid assessment on the diabetic client and is reporting information back to the experienced nurse.The student nurse notes that the client is experiencing emotional stress following his wife's recent death.Which of the following statements by the nurse student nurse regarding the effects of emotional stress indicate the need for further education?

The student nurse has measured the client's oxygen saturation level by using a pulse oximeter.The student nurse confers with the experienced nurse.Which of the following statements indicate the student nurse requires further education?

The nurse uses the nursing process to create a plan of care for a hospitalized client.Rank the following activities of the nursing process in the proper order. A)The nurse educates the client regarding the care of his sternal and leg incisions. B)The client is admitted to the hospital with chest pain.The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft. C)The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection. D)The nurse develops a plan to help prevent some of the known complications associated with surgery.

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes.Which of the following statements by the student nurse indicate that further education is required?

The nurse has assessed the hospitalized client.The nurse is preparing to document the findings using APIE.Rank the following findings in the proper order of documentation. A)The client states upon admission,"I don't know what's wrong with me,but I can't see out of my left eye and I can't stand up by myself." B)The client is unable to move from the bed to the chair without the assistance of two nurses.The client is unable to eat without assistance. C)The healthcare provider writes an order for the nurse to administer heparin. D)On the morning of the client's discharge from the hospital,the client has been able to ambulate 50 feet with a walker.

The student nurse is preparing to auscultate the client's lungs during the initial assessment.The student nurse is being assisted by the experienced nurse.Which of the following statements by the student nurse indicate the need for further education?

The client is performing an assessment of the hospitalized client.After speaking with the client,the nurse believes that the client is demonstrating altered thought processes.Which of the following statements by the client validate the nurse's conclusion?

The hospitalized client has an indwelling urinary catheter.The client has had 230 milliliters of urine collect in the drainage bag over the last 8 hours.How many milliliters of urine is the client producing on average each hour? Round to the nearest whole number. _______ milliliters per hour

The nurse is performing an initial assessment on the hospitalized client.The nurse is assessing the client's respiratory system.Rank the following steps in the correct sequence. A)The nurse percusses the client's thorax. B)The nurse unties the client's gown to better visualize the client's thorax. C)The nurse warms his stethoscope and listens to the client's lung sounds in each lung field. D)The nurse gently palpates the client's thorax.

The nurse is performing a rapid assessment for each of the following clients.Which of the following clients require immediate medical assistance?

The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital.The nurse is assessing the client's oxygenation level and the presence of jaundice.Which of the following statements by the nurse to the client indicate that the nurse is performing these specific assessments?