Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Ongoing assessment

Focused assessment

Emergency assessment

Comprehensive assessment

Answer and Explanation

The Correct Answer is A

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

A. The client will teach back information about safe crutch walking. B. The client will demonstrate safe crutch walking. C. The client will not lean on the crutches to support their body weight. D. The client will ambulate 5 feet in one day. E. The client will walk 10 feet by day 2. F. The client will walk 20 feet by day 3. G. The client will explain 4 principles of crutch safety. H. The client will explain how to keep crutches in safe condition.

Correct Answer is ["D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking.This is an essential component of client education and ensures that the client understands how to use crutches safely. However, this statement does not include a specific time frame, making it not a timed SMART goal.

B. The client will demonstrate safe crutch walking.Demonstration of skills ensures the client can safely perform crutch walking techniques. However, without a specific deadline, it does not qualify as a timed component.

C. The client will not lean on the crutches to support their body weight.This statement reinforces proper crutch technique to prevent nerve damage (e.g., axillary nerve compression). However, it lacks a specific timeframe, so it is not a timed SMART goal.

D. The client will ambulate 5 feet in one day. This goal is specific, measurable, and time-bound as it defines both the distance (5 feet) and the timeframe (one day), making it a timed SMART goal.

E. The client will walk 10 feet by day 2. This goal provides clear progression, stating that the client should ambulate 10 feet within two days, making it specific, measurable, and time-limited.

F. The client will walk 20 feet by day 3. This builds on the previous goals, ensuring incremental progress in crutch walking and clear expectations within a set timeframe.

G. The client will explain 4 principles of crutch safety.This is a knowledge-based goal that ensures the client understands the fundamentals of crutch safety. However, no specific timeframe is provided, so it is not a timed component.

H. The client will explain how to keep crutches in safe condition.This supports long-term safety and maintenance of crutches but does not specify when the client should demonstrate this knowledge, making it not a timed SMART goal.

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Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Correct Answer is B

Explanation

Correct Answer is ["D","E","F"]

Explanation

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

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