Data collection occurs where in the nursing process?

Planning

Diagnosis

Evaluation

Assessment

Answer and Explanation

The Correct Answer is D

A. Planning: Planning involves setting goals and interventions based on data collected, but data collection itself is not part of this phase.

B. Diagnosis: Diagnosis involves analyzing collected data to identify health issues, but data collection is a separate process that occurs before this phase.

C. Evaluation: Evaluation assesses the effectiveness of interventions and progress towards goals, but data collection is performed earlier in the process.

D. Assessment: Data collection is a fundamental part of the assessment phase in the nursing process, where information is gathered to identify patient needs and conditions.

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Correct Answer is C

Explanation

A. Wheezes: Wheezes are high-pitched sounds usually associated with airway constriction, such as in asthma, not specifically lobar pneumonia.

B. Rhonchi: Rhonchi are low-pitched, snoring sounds associated with secretions in the airways and may be present in pneumonia but are not the most characteristic finding.

C. Coarse crackles (rales): Coarse crackles or rales are bubbling, crackling sounds heard when air moves through fluid in the airways, which is typical in pneumonia due to the presence of alveolar fluid.

D. No sound: Absence of sound is not expected in pneumonia; adventitious sounds like crackles are usually present.

A. Pulses B. Vibrations C. Fremitus D. Temperature

Correct Answer is A

Explanation

A. Pulses: The finger pads are particularly effective for detecting the presence, strength, and regularity of pulses due to their sensitivity and the ability to apply gentle pressure.

B. Vibrations: Vibrations are best assessed with the ulnar surface of the hand rather than the finger pads.

C. Fremitus: Fremitus, or the vibrations transmitted through the chest wall, is best assessed using the palmar or ulnar surface of the hand.

D. Temperature: Temperature is more effectively assessed using the back of the hand, not the finger pads.

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Data collection occurs where in the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A senior patient is being admitted due to lobar pneumonia to the med-surgical floor. When auscultating, the nurse would expect to listen to which of the following adventitious breath sounds?

Correct Answer is C

Explanation

The nurse is using the finger pads of the hand to palpate a body part. The nurse would best be able to detect which finding?

Correct Answer is A

Explanation

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

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During the cardiac cycle, heart sounds correlate with events of the cycle. Which is being associated with systole?

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The nurse is assessing a client's cardiovascular status within the comprehensive health history. What should the nurse include in this section of the assessment? (Select all that apply.)

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?