a nurse is assessing four adult clients which of the following physical assessment techniques should the nurse use
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Nursing Elites

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1. During a physical assessment of adult clients, which of the following techniques should the nurse use?

Correct answer: B

Rationale: When performing a physical assessment, it is essential to palpate the client's abdomen before auscultating bowel sounds. This sequence helps prevent altering bowel sound results due to the pressure applied during palpation. Choice A is incorrect because the FLACC pain rating scale is typically used for nonverbal or pediatric clients, not adults. Choice C is incorrect because the bladder of the blood pressure cuff should surround about 80% of the client's arm circumference, not the bladder of the cuff itself. Choice D is incorrect because to obtain an apical heart rate, auscultation should be done at the fifth intercostal space at the midclavicular line, not at the third intercostal space to the left of the sternum.

2. What is the primary focus of strategic planning in healthcare organizations?

Correct answer: C

Rationale: In healthcare organizations, the primary focus of strategic planning is to enhance patient care quality. While financial performance, staff satisfaction, and regulatory compliance are essential aspects in healthcare management, they are secondary to the overarching goal of providing high-quality care to patients. Financial performance ensures sustainability, staff satisfaction impacts productivity and retention, and regulatory compliance maintains legal standards. However, without a core focus on improving patient care quality, the strategic planning efforts may not align with the primary mission of healthcare organizations.

3. A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Correct answer: C

Rationale: The correct answer is C: "Client was trying to get out of bed." This statement accurately reflects the sequence of events leading to the client's fall and provides crucial information for assessing the situation. Choice A is incorrect because documenting the completion of an incident report is not relevant to describing the incident itself. Choice B incorrectly states that the client climbed over the side rails, which is not supported by the information provided. Choice D is too vague and does not provide details about the client's actions prior to falling.

4. Selecting a person/unit to negotiate on the group's behalf is known as:

Correct answer: D

Rationale: The correct answer is D, representation election. Representation election is the process where individuals within a group vote to select a person or unit to represent and negotiate on their behalf. Options A and B are incorrect because they refer to the broader concepts of labor negotiations and bargaining, not specifically the process of selecting a representative. Option C, establishing a union, is also incorrect as it refers to the formation of a labor union rather than the act of choosing a representative for bargaining.

5. If the nurse and nurse manager did not resolve the situation related to the physician's report about the nurse's performance, what is the length of time allowed for the nurse to submit an appeal?

Correct answer: A

Rationale: If the informal discussion between the nurse and nurse manager does not resolve the issue regarding the physician's report on the nurse's performance, the nurse can submit a written appeal within 10 days, according to the healthcare facility policy. This 10-day timeframe ensures a prompt resolution of disputes and maintains clear communication channels within the healthcare setting. Choices B, C, and D are incorrect as they exceed the time limit allowed for the nurse to submit an appeal, which is specified to be 10 days.

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