The nurse observes a newly admitted patient in the hospital room and determines that data collection should be focused on chronic obstructive pulmonary disease. What did the nurse observe to make this decision?
a. The patient is coughing.
b. The patient is lying supine in bed.
c. The patient is walking around the room.
d. The patient is sitting in the tripod position.
ANS: D
In chronic obstructive pulmonary disease patients use accessory muscles to breathe and tend to assume the classic tripod position to aid breathing. A. B. C. Coughing, lying supine in bed and walking around the room do not necessarily indication that the patient has chronic obstructive pulmonary disease.
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All of the needed objective data on a specific health problem are available for the community health nurse. Which of the following best describes why the nurse would also interview community residents about the health problem?
a. To confirm the accuracy of the previously collected data b. To emphasize to residents the importance of the health problem c. To obtain the residents' personal insights and beliefs about the problem d. To update the previously collected data
Which nursing note reflects a normal elimination of excess fluid?
a. "Moderate lochia serosa." b. "Urine dark amber. Scant lochia alba." c. "Perspiring profusely. Vomited 200 mL clear emesis." d. "Urine pale, 2800 mL past 24 hours. Wet gown changed ? 2."
The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate?
A) Obtain a mechanical lateral transfer device to move the client onto a stretcher. B) Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher. C) Position a friction-reducing sheet under the client before attempting the transfer. D) Transport the client to the radiology department in the hospital bed.
Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss?
A) Vital sign sheet B) Intake and output sheet C) Critical care flow sheet D) Health assessment flow sheet