A focused assessment should be done by the nurse in all of the following situations EXCEPT:
patient's vital signs are B/P 120/80, P 88 and R 18
non-responsive patient
disoriented patient
critically patient ill
The Correct Answer is A
A. Patient’s vital signs are B/P 120/80, P 88, and R 18: Stable, normal vital signs do not indicate an immediate need for a focused assessment unless there is a complaint or concern.
B. Non-responsive patient: A focused neurological and airway assessment is required for an unresponsive patient.
C. Disoriented patient: Disorientation may indicate neurological issues, infection, or metabolic imbalance, requiring a focused mental status and neurological assessment.
D. Critically ill patient: Critically ill patients require frequent focused assessments based on their condition (e.g., respiratory, cardiac, or neurological).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.
B. None of the answers are correct: One of the answers is correct based on legal documentation principles.
C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.
D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.
Correct Answer is D
Explanation
A. Oxygen will be continued: Continuing oxygen therapy is an intervention, not a measurable outcome.
B. The patient's coughing frequency will increase: While coughing can help clear secretions, increased coughing does not necessarily indicate improved airway clearance.
C. Cyanosis may be present: Cyanosis is a sign of worsening oxygenation, not an improved outcome.
D. Within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea: A desired outcome should be specific, measurable, and indicate improvement. The resolution of dyspnea demonstrates effective airway clearance.
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