A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Assess respiratory rate and rhythm

Pulse oximetry reading

Assess bowel sounds

Auscultate lung sounds

Determine two touch discrimination in the lower extremities

Answer and Explanation

Correct Answer : A,B,D

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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Correct Answer is ["A","D","E"]

Explanation

A. Relief of urinary retention. Urinary catheterization is indicated for clients who cannot void effectively, which can lead to bladder distension and complications.

B. Convenience for the nursing staff or the client's family. Catheterization should never be done for staff convenience due to the high risk of infection (CAUTI - catheter-associated urinary tract infection).

C. Routine acquisition of a urine specimen. Routine urine specimens should be obtained through clean-catch or midstream methods, unless a sterile sample is required for culture and sensitivity testing.

D. Measurement of residual urine after urination. Catheterization may be needed to measure post-void residual volume in cases of urinary retention.

E. Presence of an open perineal wound. A catheter can help prevent urine contamination of an open wound in the perineal area, reducing the risk of infection.

A. 4+ B. 3+ C. 2+ D. 1+

Correct Answer is B

Explanation

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include?

Correct Answer is ["A","D","E"]

Explanation

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a urine output of 250 mL in a 24-hr period. Which of the following terms should the nurse use to document this finding in the electronic record?

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A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

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