Questions on nursing process & Vital Signs Flashcards
Which of the following is NOT one of the steps involved in the nursing process?
Assessment
Nursing clinical reasoning
Implementation
Evaluation
Nursing clinical reasoning
Assessment in the nursing process involves:
Collect data, organize data, validate data, and document data
Collect data, analyze data, validate data, and document data
Collect data, organize data, formulate diagnostic data, document data
Analyze data, identify problems, prioritize problems, and document data
Collect data, organize data, validate data, and document data.
The nurse assessed a patient’s abdomen because the patient said her abdomen hurt. What is this type of assessment?
Initial assessment
Time-lapsed assessment
Emergency assessment
Focused assessment
Focused assessment
A nurse assesses a patient’s vital signs in the morning and repeats them in the afternoon. What type of assessment is this?
Focused assessment
Time-lapsed assessment
Initial assessment
Emergency assessment
Time-lapsed assessment
The nurse meets a patient for the first time and asks the patient about his health history. What type of assessment is this
Time-lapsed assessment
Initial assessment
Focused assessment
Emergency assessment
Initial assessment
If the patient suddenly falls to the floor when walking around the unit, what kind of assessment will the nurse do?
Emergency assessment
Focused assessment
Initial assessment
Time-lapsed assessment
Emergency assessment
The nurse looked at the patient’s lab value results in the chart. The nurse obtained objective data.
True
False
TRUE
The patient asks for a warm blanket because she says she is feeling cold. This is a subjective data.
True
False
TRUE
A nurse checks a patient’s vital signs; the BP was 148/93. Which of the following actions of the nurse is correct?
Did not re-check the blood pressure during the shift
Documented the blood pressure during the next shift
BP value was within the expected range and did not report to the charge nurse.
Compared the current blood pressure with previous values
Compared the current blood pressure with previous values
It is unsafe for a patient with a blood pressure of 85/54 to ambulate without the presence of a nurse.
True
False
TRUE
A nurse assesses a patient’s apical pulse and notices irregular rhythm. The nurse will assess the pulse for at least …
60 seconds
30 seconds
15 seconds and multiply the value by 4.
30 seconds and multiply the value by 2.
60 seconds
Which breathing patterns require body positioning, such as sitting or standing, for comfortable breathing?
Orthopnea
Sleep apnea
Apnea
Bradypnea
Orthopnea
In developing a therapeutic relationship with a patient, the nurse must be respectful, trustworthy and genuine.
True
False
True
A nurse obtained a patient’s oral temperature of 38.5oC. What would be the appropriate action for the nurse to take? SELECT ALL THAT APPLY.
Ask the patient if he just took a hot drink
Obtain the temperature from the axilla
Do not document the initial temperature reading
Document the initial temperature only and report it to the patient’s family.
- Ask the patient if he just took a hot drink
- Obtain the temperature from the axilla
