A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

Document information directly from a textbook.

Copy previous nursing assessment.

Document their findings.

Seek clarification from a more experienced nurse.

Answer and Explanation

The Correct Answer is D

A. Documenting information directly from a textbook is incorrect because textbooks provide general guidelines, not client-specific data. The student's assessment findings should be based on the actual client’s condition.
B. Copying a previous nursing assessment is incorrect and unethical. Each assessment must be conducted independently to ensure accurate and up-to-date client care.
C. Documenting findings without confidence in their accuracy can lead to errors in client care. If the student is uncertain, verification is necessary before documentation.
D. Seeking clarification from a more experienced nurse is correct. If a student nurse is unsure of their assessment findings, they should ask a preceptor or experienced nurse for guidance to ensure accuracy and safe client care.

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Correct Answer is B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. Air being diverted from the trachea to the bronchi B. Air passing through constricted passageways C. Air increasing in turbulence in a wide passage D. Air leaking from the alveoli into the pleural space

Correct Answer is B

Explanation

A. Air being diverted from the trachea to the bronchi does not explain the cause of a wheeze. This is a normal part of airflow distribution.
B. Air passing through constricted passageways is correct. A wheeze is a high-pitched, musical sound that occurs when air flows through narrowed or obstructed airways, as seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), or bronchitis.
C. Air increasing in turbulence in a wide passage is incorrect. Wheezing occurs due to airway narrowing, not widening.
D. Air leaking from the alveoli into the pleural space describes pneumothorax, which presents with absent breath sounds rather than wheezing.

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A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student correctly describes a risk diagnosis by which of the following statements?

Correct Answer is B

Explanation

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

Correct Answer is B

Explanation

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. How would the nurse document this finding?