An LPN bridging to RN is collecting an admission history. Which finding is the most important to document and report first?
Assessment
Question · Easy
Which technique is correct when assessing the abdomen?
An adult client's blood pressure is 138/86 mm Hg on routine assessment. According to current ACC/AHA guidelines, this reading is best classified as:
Question · Medium
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Which finding obtained during a head-to-toe assessment is the priority concern?
When assessing a client's pain, which approach is most appropriate?
A client reports a productive cough with thick green sputum. Which additional assessment data is most important to obtain?
Which client behavior best supports a finding of effective coping during an admission interview?
When obtaining an orthostatic blood pressure measurement, the nurse should:
Which sign indicates fluid volume deficit in an adult client?
While assessing a postpartum client 2 hours after vaginal birth, the nurse notes a boggy uterus displaced to the right. The most likely cause is:
Which pediatric finding requires the most immediate follow-up?
An older adult on furosemide reports leg cramps. The nurse should specifically assess for signs of:
When assessing a client who speaks limited English, the most appropriate action is to:
A client's serum sodium is 152 mEq/L. The nurse should assess for which clinical manifestation?
Question · Hard
A nurse observes a stage 2 pressure injury on a client's sacrum. The expected finding is:
Which finding in a client receiving total parenteral nutrition (TPN) is most concerning?
Which assessment data best supports a goal of improving sleep hygiene?
When auscultating the lungs of a client with pulmonary edema, the nurse expects to hear:
A nurse using the SBAR communication tool would place a recent set of vital signs in which section?
Which technique is correct for assessing peripheral pulses for amplitude documentation?
Which finding suggests poor peripheral perfusion in an older adult?
The nurse uses the Glasgow Coma Scale (GCS) on a client with a head injury. A score of 8 is best interpreted as:
A healthy term newborn's normal heart rate range is approximately:
Which assessment best evaluates fluid status in a client with heart failure?
Planning
Which nursing diagnosis should be prioritized for a client admitted with acute pulmonary edema?
A correctly written, measurable client outcome would state:
Using Maslow's hierarchy, which need takes priority for a confused, hypoxic client?
When developing a discharge plan for an older adult after hip arthroplasty, which intervention should be included first?
Which goal is appropriate for a client with the nursing diagnosis 'Impaired Skin Integrity related to immobility'?
An RN delegates client care to an LPN/LVN. Which task is appropriate to delegate?
Which client should the charge nurse assign to a new graduate RN?
When prioritizing care for four clients, which should the nurse see first?
Which long-term goal is appropriate for a client newly diagnosed with type 2 diabetes?
When planning care for a client at risk for falls, the priority intervention is to:
An RN is creating an individualized care plan for a hospitalized child. Which person should be considered the most important member of the planning team?
A client refuses a prescribed medication. The nurse's first action is to:
A nurse is planning care for a client with a do-not-resuscitate (DNR) order. Which statement is correct?
Which client requires the highest priority intervention?
An evidence-based fall risk plan for an older adult would include all of the following EXCEPT:
Which nursing care approach best demonstrates cultural humility?
Which interdisciplinary referral is most appropriate for a client newly admitted with a stage 3 sacral pressure injury?
Which initial education approach is most appropriate for a client with low health literacy?
When developing a plan to prevent infection in a client with neutropenia, which intervention should be included?
Which short-term goal best reflects pain management for a client postoperative day 1?
Which nursing diagnosis takes priority for a client immediately after thoracentesis?
When delegating to assistive personnel (AP), the RN should:
Which finding indicates a need to revise the care plan for a client receiving enteral feeding?
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