Nokea
Patient's vital signs are B/P 120/80, P 88, and R 18; Non-responsive patient; Disoriented patient; Critically ill patient
A focused assessment should be done by the nurse in all of the following situations EXCEPT:
- A. patient's vital signs are B/P 120/80, P 88 and R 18
- B. non-responsive patient
- C. disoriented patient
- D. critically patient ill
Correct Answer: A
Rationale: Stable vital signs (A) do not require a focused assessment unless indicated. B, C, and D signal urgent conditions needing targeted evaluation.
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Patient with a nursing diagnosis of airway clearance, ineffective
The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
- A. oxygen will be continued
- B. the patient's coughing frequency will increase
- C. cyanosis may be present
- D. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
Correct Answer: D
Rationale: The desired outcome for ineffective airway clearance (D) is measurable improvement, like no dyspnea within 24 hours. A is an intervention, B does not ensure clearance, and C indicates worsening.
During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?
- A. block
- B. by exception
- C. focused
- D. SOAP
Correct Answer: B
Rationale: Charting by exception (B) documents only significant changes or deviations, not routine care. Block (A) covers entire shifts, focused (C) targets specific issues, and SOAP (D) follows a structured format.
Which of the following is an example of good charting?
- A. No complaints of pain or discomfort.'
- B. The patient states, 'It feels like a knife stabbing me.'
- C. Lump diminished.'
- D. Patient's condition much better today than yesterday.'
Correct Answer: B
Rationale: Quoting the patient's exact words (B) is precise and clear. A lacks verification, C is vague, and D lacks measurable detail.
To what does objective data refer when assessing a patient?
- A. the provider's observed data
- B. All of the answers are correct
- C. the patient's perception of provided data
- D. the patient's request for information
Correct Answer: A
Rationale: Objective data (A) includes measurable findings by the provider, like vital signs. C and D are subjective, and B is incorrect as only A is accurate.
When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.