When performing a respiratory assessment, a nurse should include which of the following? Select all that apply
1. Oxygen saturation
2. Use of accessory muscles
3. Skin color
4. Respiratory rate
5. Cough
ANS: 1, 2, 3, 4, 5
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After completing nutritional screening with a client, the nurse identifies the diagnosis of imbalanced nutrition: less than body requirements. What should the nurse identify as a realistic goal for this client?
a. Increase fat in the diet 2b. Replace sweets with high-protein foods c. Increase weight by one pound per week d. Decrease physical activity to 2 hours per week
A female patient is seen for "increased hoarseness" and "a change in voice quality." What is an appropriate assessment question for the nurse to ask this patient?
1. "What medications are you currently taking?" 2. "Have you recently had a cold?" 3. "Have you recently visited another country?" 4. "What is your occupation?"
After instructing the patient in using the incentive spirometer (IS), the nurse instructs nursing assistive personnel (NAP) to encourage the patient to use it. What does the nurse provide to the NAP as a rationale for using the IS after surgery?
a. It helps to maintains venous return. b. It helps to reexpand the lungs. c. It prevents any type of respiratory infec-tion. d. It decreases the blood pressure.
The client has chronic alcoholism. Which lab test is most important for the nurse to evaluate?
1. Liver function test 2. Complete blood count 3. White blood count 4. Stool for occult blood