Nokea
The purpose of a health assessment is to:
- A. Obtain subjective and objective data
- B. Outline appropriate care
- C. Determine whether interventions are effective
- D. Intervene to correct difficulties
Correct Answer: A
Rationale: Health assessments collect subjective and objective data to inform care planning. Outlining care, evaluating interventions, or correcting issues are subsequent steps.
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The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
The nurse is teaching a group of clients strategies to promote effective sleep. The nurse should recommend that the clients Select all that apply.
- A. Empty their bladder before bed.
- B. Take more naps throughout the day.
- C. Eat a high amount of calories before bed.
- D. Plan vigorous exercise earlier in the day.
- E. Use multiple nightlights in the bedroom.
Correct Answer: A,D
Rationale: Emptying the bladder and exercising early promote sleep. Naps, high-calorie meals, and multiple lights disrupt sleep hygiene.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should
- A. Clean the wound with sterile saline.
- B. Pat dry the wound with gauze.
- C. Irrigate the wound with hydrogen peroxide.
- D. Don sterile gloves
Correct Answer: A
Rationale: Cleaning with sterile saline removes debris, ensuring an accurate culture. Drying, using peroxide, or sterile gloves (clean gloves suffice) are not appropriate.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 2 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
The nurse reviews the assessment data and analyzes the individual's risk for falling. Click to specify whether each assessment finding is a risk factor for falling or not.
- A. Ambulation pattern
- B. Speech pattern
- C. Age
- D. Gender
- E. Fall history
- F. Current medications
Correct Answer: A,C,E,F
Rationale: Ambulation pattern, age (older adults), fall history, and medications (e.g., diazepam) are fall risk factors. Speech pattern and gender are not direct risk factors.