The LPN/LVN understands the four activities involved in assessment include: Standard Text: Select all that apply
1. Gathering information about a client.
2. Organizing data.
3. Documenting data.
4. Measuring responses to nursing interventions.
5. Validating data.
1,2,3,5
Rationale 1: Data collection is a systematic process of gathering information about a client.
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The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.)
a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning
A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation?
a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination
The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?
a. Gently tap over the site. b. Apply a cold compress to the site. c. Raise the extremity above the level of the body. d. Use a rubber band as a tourniquet for 5 minutes.
After the nurse has received change-of-shift report, which patient should the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity