NUR 111 Unit 2

Which action is an example of the assessment phase of the nursing process?

• Administering medication to a client in pain

• Obtaining a blood pressure after the client has ambulated

• Determining if the client has tolerated a change in diet

• Communicating discharge instructions to a client

A nurse identifies the following for a client : "Ambulate 50 feet in the hall twice daily." Which step of the nursing process does this reflect?

• Assessment

• Planning

• Evaluating

• Implementation

The nurse assesses client following administration of an anti emetic to a client experiencing nausea and vomiting. What phase of the nursing process does this demonstrate?

• Assessment

• Evaluation

• Diagnosis

• Implementation

The nurse is using ISBAR communication during a crisis. What nursing intervention reflects the R step of this technique?

• Recording the reaction of the client to the crisis

• Reassessing the client after medical intervention

• Recommending a potential action to manage the crisis

• Reporting the situation to primary health care provider

Which is an acceptable practice when documenting in a client's medical record?

• Only chart for another nurse in an emergency

• Always initial an entry before adding a comment to a previously written note

• When documenting an opinion, such as "The client is demanding" also use examples of the client's behavior

• For an addendum to a note, enter the current date and tame and the word addendum

The nurse is caring for a client with presbyopia. Select ALL of the appropriate nursing interventions.

• Make sure the client has adequate lighting

• Speak in a lower tone

• Clear the path of any clutter

• Speak so the client can see your mouth

• Minimize background noise

The nurse at a long term skilled nursing facility is caring for a client admitted one week ago following an extended hospital stay. The client is on bedrest in a private room. Family has not been present for several days. The client is at risk for:

• Sensory Overload

• Sensory Deprivation

• Sensory Deficit

• Sensory Perception

A client needs to learn how to take their pulse before taking a prescribed heart medication. Before beginning client teaching, the nurse needs to evaluate which of the following about the client?

• Apical heart rate and rhythm

• Reading ability

• Support system at home

• Motivation

The nurse can best evaluate a client's ability to self-administer enoxaparin injection by which of the following methods?

• Have the client write out the steps of the procedure.

• Demonstrate the technique using an orange.

• Show the client a video on how to administer the injection.

• Have the client administer their own enoxaparin injection.

Which of the following behaviors by a client indicates to the nurse that learning in the cognitive domain has taken place?

• Explaining the rationale for taking a new medication

• Actively demonstrating the new skill

• Telling the nurse the client has accepted the illness and its effects on lifestyle

• Physically demonstrating insulin injections