A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.

Which of the following sources of information should the nurse rely on for accurate information about the client?

The client

Progress note

Medical history

Family information

Answer and Explanation

The Correct Answer is A

A. The client:

The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.

B. Progress note:

Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.

C. Medical history:

The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.

D. Family information:

Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Take the blood pressure:

Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.

B. Remove the pillow from under the patient’s head:

Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.

C. Elevate the foot of the bed:

Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.

D. Elevate the head of the bed:

Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.

A. “Do you want to talk about your health concerns?” B. “Would it help to discuss your feelings about this hospitalization?” C. “Would you tell me about all of your medical issues?” D. “What brought you to the hospital?”

Correct Answer is D

Explanation

A. "Do you want to talk about your health concerns?"

While this question acknowledges the client's option to discuss health concerns, it is somewhat closed-ended and might not prompt the client to share specific details.

B. "Would it help to discuss your feelings about this hospitalization?"

This question addresses the client's feelings about the hospitalization, which is important for emotional well-being, but it might not directly elicit information about the client's primary health issues.

C. "Would you tell me about all of your medical issues?"

This question is somewhat open-ended but might be overwhelming for the client. It is more effective to start with a focused question about the reason for seeking care.

D. "What brought you to the hospital?"

This open-ended question encourages the client to share their primary reason for seeking healthcare and allows for a comprehensive discussion about the client's health concerns. It gives the client an opportunity to express their own perspective and share the relevant information about their medical condition or symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is having dyspnea. What would the nurse do first?

Correct Answer is A

Explanation

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is D

Explanation

A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? (Select all that apply.)

A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur. Which of the following best describes the sound of a heart murmur?

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is? What is the appropriate response by the instructor?

Ordered: Hydroxyzine (Vistaril) 35 mg IM stat Available: Hydroxyzine (Vistaril) 50 mg/mL Administer: ____ ml

A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit.

Which of the following sources of information should the nurse rely on for accurate information about the client?