It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

the beginning of each shift.

admission to the unit.

discharge.

the patient's wakening in the morning.

Answer and Explanation

The Correct Answer is A

A.   Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B.   While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C.   At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D.   While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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Correct Answer is B

Explanation

A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.

A. check the patient's record to determine his baseline blood pressure. B. notify the charge nurse of the hypotension. C. check medications that might be the cause of the irregularity. D. notify the doctor of the bradycardia.

Correct Answer is A

Explanation

A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

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It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

Correct Answer is B

Explanation

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

The nurse taking a blood pressure should:

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

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

The nurse taking an apical pulse would place the stethoscope at:

When performing an initial assessment on a patient, which piece of information is of highest priority?

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)