The nurse utilizes the data from the interview to complete which step of the nursing process?
1. assessment
2. diagnosis
3. implementation
4. evaluation
ANS: 2
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The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply
a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute
A nurse hears a 5-year-old patient who just started kindergarten use rude vocabulary. What is the best response to this behavior?
a. Ignore it. b. Speak to his teacher about it. c. Praise him when he speaks properly. d. Talk about it at the parent–teachers asso-ciation.
The nurse is preparing to administer a dose of growth hormone and reconstitutes the medication. After adding the diluent, the nurse notices that the preparation is cloudy. What action should the nurse take?
a. The drug should be administered as ordered. b. The drug should be discarded and another dose prepared. c. The drug should be shaken to help dissipate the particles. d. The charge nurse and prescriber should be notified.
The nurse is performing a physical assessment on a newborn diagnosed with galactosemia. Which of the following are signs present in newborns with this disorder? Select all answers that apply
A) Cyanosis B) Jaundice C) Mental retardation D) Heart defects E) Vomiting F) Urinary retention