A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Assess respiratory rate and rhythm

Pulse oximetry reading

Assess bowel sounds

Auscultate lung sounds

Determine two touch discrimination in the lower extremities

Answer and Explanation

Correct Answer : A,B,D

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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Correct Answer is B

Explanation

A. Dysuria. Dysuria refers to painful or difficult urination, not low urine output.

B. Oliguria. Oliguria is defined as urine output less than 400 mL in 24 hours, which fits this case (250 mL in 24 hours).

C. Nocturia. Nocturia is frequent urination at night, not low urine output.

D. Urgency. Urgency refers to a sudden, strong need to urinate, not decreased urine production.

A. Assess fluid balance. B. Introduce a regular diet. C. Rehydrate. D. Maintain fluid therapy.

Correct Answer is C

Explanation

A. Assess fluid balance. While assessment is important, treatment of dehydration (rehydration) is the priority in severe diarrhea.

B. Introduce a regular diet. Introducing a regular diet should come after rehydration, as severe diarrhea can lead to fluid and electrolyte imbalance that must be corrected first.

C. Rehydrate. The immediate priority is fluid replacement (oral or IV) to prevent hypovolemia, electrolyte imbalances, and shock.

D. Maintain fluid therapy. Maintaining fluid therapy is important after rehydration has begun, but initial rehydration is the priority intervention.

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A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a urine output of 250 mL in a 24-hr period. Which of the following terms should the nurse use to document this finding in the electronic record?

Correct Answer is B

Explanation

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply.)

The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

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