ADN 2024 CDM

The nurse receives a shift report and is preparing to care for clients assigned on a medical-surgical unit. Which client should the nurse plan to assess first?

• The client who needs assistance with a bath.

• The client who needs help ambulating to the bathroom.

• The client with a pain rating of 3/10.

• The client experiencing shortness of breath.

A client with congestive heart failure (CHF) is having difficulty breathing. Before leaving the room, the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision?

• Delegating a task

• Priority setting

• Conflict resolution

• Critical thinking

A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action?

• Notify the healthcare provider

• Complete a thorough cardiopulmonary assessment

• Administer 10L of oxygen per face mask

• Reposition the client to help with breathing

A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. In which way should the student respond?

• "I do not know, but I will find out."

• "You'll have to ask the doctor that question."

• "Why do you need to know that?"

• "I do not know."

A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking?

• Discuss the plan with the physician.

• Request a review of the plan with the nurse's preceptor.

• Request that the client review the plan.

• Place the plan on the client's chart.

An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client?

• Complete all nursing care at the end of the shift.

• Delegate care for the client to an aide.

• Complete all nursing care in the morning.

• Pace nursing care throughout the shift.

A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, which action should the nurse take?

• Ask the client about readiness to walk.

• Evaluate the client's level of pain.

• Conduct a breathing assessment.

• Call for a wheelchair to start the process.

The nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these actions represent? Select all that apply.

• Assessment

• Diagnosis

• Planning

• Implementation

• Evaluation

The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs.

A) Bleeding through nasogastric tube

B) Audible wheezes

C) Not understanding how to complete the menu

D) Requesting medication for arthritis pain

E) Dyspnea

F) Asking questions about teaching provided the other day

• EBADFC

• ABECDF

• BEADFC

• ABCDEF

The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan? Select all that apply.

• Medications

• Nursing Diagnosis

• Goals

• Interventions

• Evaluation