What is the primary purpose of validation as a part of assessment?
A) to identify data to be validated
B) to establish an effective nurse–patient communication
C) to maintain effective relationships with coworkers
D) to plan appropriate nursing care
D
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A patient who is 5 feet 5 inches tall and weighs 144 lbs asks the nurse if she would be considered obese. How should the nurse respond to this patient?
1. "You are a normal weight for your height." 2. "Yes, you are slightly obese for your height." 3. "You are slightly overweight." 4. "You are moderately obese."
During the fourth stage of labor, the nurse assesses the client's fundal height and tone. While completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus?
A) Place the index and middle fingers across the muscle B) Palpate the abdomen while feeling the uterine fundus C) Massage the fundus carefully to expel any blood clots D) Place a gloved hand just above the symphysis pubis
A nurse is providing oral care to a client with dentures. What action would the nurse do first?
A) Assess the mouth and gums. B) Don gloves. C) Wash the client's face. D) Apply lubricant.
Which assessment finding warrants the nurse to hold the dosage of benztropine (Cogentin) and notify the healthcare provider?
A. A respiratory rate of 14 B. A pulse of 112 C. Blood pressure of 142/80 mmHg D. A temperature of 100.2°F