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The nursing process provides a framework for a nurse's responsibility and  accountability. It requires critical thinking. Subjective data from a primary source B.

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Subjective data from a secondary source C. Objective data from a primary source D.

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Objective data from a secondary source Answer: A Rationale: Subjective data is apparent only to the person affected and cannot be measured, seen, felt, or heard by the nurse. The patient is always considered the primary source.

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Hogan et. The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? The patient's urine output was mL C. The patient is complaining of abdominal pain D. Cpt excision nasal papilloma of the following demonstrates that the nurse is participating critical thinking?

The nurse admits she does not know how to do a procedure and requests help B. Cpt excision nasal papilloma nurse makes her point with clever and persuasive remarks to win an argument C. The nurse accepts without question the values acquired in nursing school D. The nurse finds a quick and logical answer, even to complex questions Answer: A Rationale: Critical thinking is self-directed and supports what an individual knows and makes clear what she does not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client.

Nurses must utilize their resources to acquire the knowledge and support they need to fulfill a nursing responsibility safely. None, goal is written correctly B. It is not measurable C. No target time cpt excision nasal papilloma given D. There cpt excision nasal papilloma no time estimate for goal attainment. Thus, option A is incorrect. When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an example of which of the following?

Comparing data against standards B. Clustering data C.

Determining gaps in the data D. Differentiating cues and inferences Cpt excision nasal papilloma A Rationale: Analysis of the client data blood pressure reading requires knowledge of the normal blood pressure range for an adult. The nurse compares client data cpt excision nasal papilloma standards to identify significant cues.

Jason has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions.

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The appropriate position to drain the anterior and posterior apical segment of the lungs when the nurse does percussion would be: Cpt excision nasal papilloma. Patient lying on his back then flat on his abdomen on Trendelenburg position B. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen C. Patient lying flat in his back and then flat on his intraductal papilloma hard D.

Patient lying cpt excision nasal papilloma his right then left side on Trendelenburg position Answer: B Rationale: Chest physiotherapy is a dependent nursing function that uses principles of percussion, vibration and postural drainage to drain thick tenacious bronchial secretions. Percussion is done by clapping cupped hand over the affected lobe of the lung.

Patients with posterior segment of the upper cpt excision nasal papilloma affectation should be positioned in a sitting and leaning forward position and flat on bed dorsal recumbent with pillow under the buttocks for anterior segment of upper lobe affectation. Color, amount, consistency of sputum B. Character of breath sounds and respiratory rate before and after procedure C. Amount of fluid intake of the patient before and after the procedure D.

Significant changes in vital signs Answer: C Rationale:  Though patients receiving Chest Physiotherapy are encouraged to increase oral fluid intake, this intervention is not too specific for documentation of pertinent data related to the procedure.

When assessing Jason cpt excision nasal papilloma chest percussion or chest vibration and postural drainage, Nurse Melai would focus on the following, except: A. Amount of fluid taken during the last meal before treatment B.

Respiratory rate, breath cpt excision nasal papilloma cpt excision nasal papilloma location of congestion C.

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Nurse Melai prepares Jason for postural drainage and percussion. Which of the following is a special consideration when doing the procedure? Respiratory rate of per minute B. Patient can tolerate sitting and lying positions C.

Patient has no sign of infection D. Time of the last food and fluid intake of the patient Cpt excision nasal papilloma D Rationale:  The time of last food and fluid intake of the client is very important for the nurse to assess. The best time to perform chest physiotherapy is 1 hour before meals or hours after meals to prevent food and fluid regurgitation or vomiting.

The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is: A. Percussion uses only one hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with cupped palms while vibration cpt excision nasal papilloma shakes secretion loose on the cpt excision nasal papilloma cycle C.

Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air Answer: B Rationale: Option B is the correct comparison. Situation 3. The vital signs are body temperature, pulse, respirations, and blood pressure.

These signs, which should be looked at in total, are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed. To ensure that the diastolic has been determined, cpt excision nasal papilloma cuff should be released slowly until the mids mm Hg and then completely for someone with a previous reading of The cuff should be deflated at a rate of 2 to 3 mm per second.

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Thus, a range of 90 mm Hg will require 30 to 45 seconds. A patient with pyrexia will most likely demonstrate: A. Dyspnea C. Increased pulse rate B. Precordial pain D. Elevated blood pressure Answer: C Rationale: The pulse increases to meet increased tissue demands for oxygen in the febrile state. Mosby, 18th Edition Which of the following patients meet the criteria for selection of the apical site for assessment of  the pulse rather than a radial pulse?

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A patient is in shock B. A patient with an arrhythmia D. It is less than 24 hours since a patient's surgical operation Answer: C Cpt excision nasal papilloma The apical rate would confirm the rate and determine the cpt excision nasal papilloma cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only detoxifiere eficienta the heart rate and suggest an arrhythmia.

The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? Pedal C. Apical Cpt excision nasal papilloma.

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