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A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding

Stop administering the tube feeding and assist the client who spilled coﬀee with changing her wet clothing and

assess for burns

Request a replacement tray and assist the client with changing her wet clothing

Answer and Explanation

Correct Answer : B

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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Correct Answer is ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

A. Identify outcomes B. Planning C. A “risk for” nursing diagnosis D. Implementation

Correct Answer is ["A"]

Explanation

Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.

Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reﬂects the client’s priorities and resources. Therefore, this choice is correct.

Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,

but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.

Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.

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A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

Correct Answer is ["B"]

Explanation

In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Correct Answer is ["A"]

Explanation

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

A nurse is caring for a client who is hearing-impaired and takes which approach to best facilitate communication? (Select all that apply)

The client does not speak English; therefore, the Practical Nurse (PN) cannot use words to provide comfort during a painful procedure. The PN selects another intervention to provide comfort, which is: * Select one answer

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What should the nurse do with linens that have been soiled by a client with hepatitis?

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?