While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

The patient's spouse reports experiencing marital issues.

The patient reports a history of chest pain.

The patient complains of chronic constipation.

The patient verbalizes anxiety about hospitalization.

Answer and Explanation

The Correct Answer is A

A.   The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B.   The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C.   The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D.   The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

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Correct Answer is B

Explanation

A: Rales are described as fine crackling sounds, not high-pitched crowing.

B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.

A. The nurse applies pressure over a bony prominence of the foot for 2 seconds. B. The nurse percusses the tissue that appears edematous C. The nurse elevates the patient's feet on a pillow to decease swelling. D. The nurse charts, "Patient's feet appear to be swollen."

Correct Answer is A

Explanation

A: Applying pressure over a bony prominence helps assess for pitting edema, a common indicator of fluid retention causing swelling. This action provides objective data to confirm the patient's subjective observation.
B: Percussion is not typically used to assess edema. It is more suitable for assessing the density of underlying structures.
C: Elevating the feet may help alleviate swelling but does not confirm the presence of edema.
D: Documenting the observation is important, but further assessment is needed to confirm the patient's concern.

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While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

Correct Answer is B

Explanation

The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

Correct Answer is A

Explanation

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?