It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

the beginning of each shift.

admission to the unit.

discharge.

the patient's wakening in the morning.

Answer and Explanation

The Correct Answer is A

A.   Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B.   While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C.   At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D.   While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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Correct Answer is A

Explanation

A. The newborn’s head is a major source of heat loss due to the large surface area and insufficient
insulation. Covering the head helps maintain body temperature.
B. While the head can be reshaped, the primary reason for covering it is to prevent heat loss, not reshaping.
C. The head is not necessarily wet and doesn't require drying in all cases, making this less relevant.
D. Although the head has large fontanels, this is not the reason it is covered with a cap; preventing heat loss is the priority.

A. auscultate for bowel sounds once a shift. B. auscultate lung sounds at the beginning of a shift. C. monitor for skin turgor every shift. D. monitor peripheral pulses once a shift.

Correct Answer is B

Explanation

A. Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B. Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C. Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D. Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse covers a newborn baby's head with a cap. because the head:

Correct Answer is A

Explanation

A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Correct Answer is B

Explanation

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

A very pertinent part of the physical examination on a patient with back pain is

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The normal pattern of breathing is described as

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An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a: