#1
Which of the following is NOT a component of a comprehensive nursing assessment?
Treatment plan
ExplanationTreatment plan is not assessed but rather formulated based on assessment findings.
#2
During a nursing assessment, which action should the nurse prioritize?
Performing a comprehensive physical examination
ExplanationPhysical examination provides foundational data for nursing interventions.
#3
Which of the following is an example of objective data in a nursing assessment?
The patient's blood pressure is 120/80 mmHg
ExplanationObjective data is measurable and observable, providing concrete information.
#4
When assessing a patient's skin turgor, which finding indicates dehydration?
Skin remains elevated for several seconds
ExplanationDelayed return of skin to normal position suggests dehydration.
#5
Which nursing action is appropriate during the assessment phase of the nursing process?
Assessing the patient's vital signs
ExplanationVital signs provide baseline data essential for ongoing patient evaluation.
#6
What is the primary purpose of the Braden Scale in nursing practice?
To assess risk for pressure ulcer development
ExplanationThe Braden Scale evaluates factors contributing to pressure ulcer risk.
#7
Which critical thinking skill involves recognizing when to consult with other healthcare professionals?
Collaboration
ExplanationCollaboration leverages expertise for holistic patient care.
#8
A patient presents with sudden chest pain. The nurse's immediate action should be to:
Notify the physician
ExplanationPhysician notification ensures timely intervention for potentially serious conditions.
#9
Which of the following is a priority when assessing a patient's airway?
Ensuring patency
ExplanationMaintaining airway patency is crucial for oxygenation and ventilation.
#10
When conducting a neurological assessment, which finding would be of most concern?
Weakness on one side of the body
ExplanationUnilateral weakness may indicate neurological compromise or stroke.
#11
Which nursing action best demonstrates the application of clinical judgment?
Reassessing a patient's condition after interventions
ExplanationReassessment ensures effectiveness of interventions and guides further actions.
#12
During a physical examination, which technique should the nurse use to assess lung sounds?
Auscultation
ExplanationAuscultation allows for the detection of abnormal breath sounds.
#13
Which statement best describes the purpose of a nursing diagnosis?
To guide nursing interventions
ExplanationNursing diagnosis directs specific interventions to address patient needs.
#14
Which aspect of critical thinking involves examining assumptions and biases?
Analysis
ExplanationAnalysis involves dissecting information to uncover underlying assumptions.
#15
When conducting a nutritional assessment, which parameter is the most reliable indicator of a patient's nutritional status?
Serum albumin level
ExplanationSerum albumin reflects long-term protein status, indicative of overall nutrition.