Author Question: The nurse works on a medical-surgical unit. Which clients will require a rapid assessment? Select ... (Read 194 times)

mia · **on:** Jun 25, 2018

The nurse works on a medical-surgical unit. Which clients will require a rapid assessment? Select all that apply.

1. The client had an open appendectomy 2 days ago and is preparing to be discharged today.
2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.
3. The client has just been received from the Post Anesthesia Care Unit.
4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.
5. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93 on room air this morning to 87.

Question 2

The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the activities of the nursing process in the proper order. Select the correct choice from the list.

1. The nurse educates the client regarding the care of his sternal and leg incisions.
2. The client arrives at the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft.
3. The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection.
4. The nurse develops a plan to help prevent some of the known complications associated with surgery.

Jane · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3, 4, 5
The nurse should perform a rapid assessment on a client following a surgical procedure. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. The nurse should perform a rapid assessment on a client who is in distress. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. The client who has been admitted to the unit the day before requires a routine assessment.

Answer to Question 2

Correct Answer: 2, 3, 4, 1
The steps of the nursing process begin with the assessment phase. The nurse assesses the objective and subjective information about the client. The second step is to create a nursing diagnosis using NANDA nursing labels. The third step is to develop a plan to help the client heal and prevent the development of complications. The fourth step is to implement nursing interventions that are based on the developed plan. The last step is to evaluate how well the nurse's plan for the client worked.