Foundations PN I Unit 1 Review

Which of the following clients would the nurse assess first?

• client with nausea and vomiting

• client with knee pain, a 6 on pain scale

• postoperative client with a low blood pressure

• a client who has questions about new medications

Which client should be assessed first?

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When prioritizing interventions to perform for a client, the nurse is aware that which task should be performed LAST? (all tasks are for one single patient)

• daily bed linen change

• recheck patient's blood pressure

• change a soiled dressing on patient's wound

• administer morning medications

The nurse should address which client FIRST?

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Which part of the nursing process is being shown in this picture?

• planning

• nursing diagnosis

• assessment

• intervention

Which of the following would be performed during the assessment phase of the nursing process? SELECT ALL THAT APPLY

• changing a dressing on the client's wound

• checking to see if a breathing treatment was effective

• client interview and history

• reviewing the physician's notes

• deciding which interventions should be used

Which of the following are symptoms? Select all that apply

• sore throat

• headache

• excessive sweating

• vomiting

• nausea

The nurse is caring for a client who has the following nursing diagnosis:

Risk for injury related to neurologic impairment and muscular weakness, as evidenced by inability to bear weight on left leg. Which of the following would be an example of a realistic and attainable goal (outcome) for this client?

• The client will not suffer injury from fall during this hospital stay.

• The client will learn to put clothes in right extremities before discharge.

• The client will ambulate with a cane independently by 08/20. (4 days)

• The client will urinate in the urinal every 2 hours while awake without episodes of urinary incontinence by 8/26. (10 days)

Which intervention is time-flexible?

• administering an intravenous antibiotic 30 minutes prior to surgery.

• administering 9:00 morning medications

• administering a bed bath

• inserting a nasogastric tube as ordered to relieve gastric distention

A client states to the nurse "I don't have much of an appetite." The nurse uses the steps of problem-solving to address this problem. When using this method, what should the nurse do first?

• consider alternatives such as offering protein shake supplements or offering favorite foods

• choose the alternative with the best chance of success

• identify the problem, such as food likes/dislikes or gastrointestinal issues such as nausea

• consider the outcomes of the chosen alternative