What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

question the patient about shortness of breath

palpate the chest and back for masses

inspect the skin and nails for integrity and color

Ask the patient about color and quantity of sputum

auscultate for lung sounds anteriorly and posteriorly

Answer and Explanation

Correct Answer : A,D

A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.

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Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may not be responsive to the unique cultural needs of each client.
B. Focusing solely on hospital unit workflow prioritizes efficiency over individualized patient care, which may not respect cultural differences.
C. This approach fails to acknowledge the diverse values and beliefs of clients, which can lead to miscommunication and unmet needs.
D. This implies a top-down approach to care, which may disregard the client’s preferences and cultural context.
E. Honoring the client's differences and perspectives demonstrates the nurse's commitment to culturally responsive care, ensuring that care is tailored to meet the unique needs of each client.

A. Have client use the incentive spirometer every hour B. Help client dangle legs off the side of the bed C. Encourage the client to ambulate as soon as possible D. Keep the client in bed with knees elevated E. Limit the amount of fluid the client drinks

Correct Answer is B

Explanation

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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What subjective data should the nurse obtain about a client's respiratory status? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?

Correct Answer is E

Explanation

The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

Correct Answer is B

Explanation

A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

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