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All of the following patients have been admitted to the acute care setting. On admission which patient should receive a focused assessment?
- A. 53-year-old admitted with a perforated ulcer
- B. 5-year-old admitted for the implant of grommets in the middle ear
- C. 76-year-old admitted for a knee replacement
- D. 40-year-old admitted for possible bowel obstruction
Correct Answer: A
Rationale: A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.
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A systematic method by which nurses plan and provide care for patients is known as the nursing ____
Correct Answer: process
Rationale: The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.
What expected outcome exemplifies accepted criteria?"
- A. Nurse will assess vital signs every day
- B. Resident will observe safety guidelines while smoking
- C. Resident will take part in one activity daily for the next 90 days
- D. Nurse will monitor O2 saturation to maintain at greater than 90%
Correct Answer: C
Rationale: Expected outcomes must be patient-centered, measurable, and refer to a time frame.
During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient complains of chest pain.
- B. The patient states "I feel nauseous."
- C. The patient complains of feeling faint.
- D. The patient is short of breath on exertion.
Correct Answer: D
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.
Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
- A. Health care provider
- B. LPN/LVN
- C. RN
- D. Technician
Correct Answer: C
Rationale: The RN is responsible for analyzing and interpreting data.