CNO CNO - College of Nurses of Ontario Health Assessment and Clinical Decision Making 3

Question 1

A nurse is assessing a client who is newly admitted with heart failure. Which assessment finding requires immediate intervention?

Accepted Answer

Respiratory rate of 28 breaths/min with use of accessory muscles

Answer

Blood pressure of 118/76 mmHg

Answer

Temperature of 37.1°C

Answer

Heart rate of 80 bpm and regular

Question 2

When documenting a health assessment finding as 'WNL,' what does this abbreviation mean?

Accepted Answer

Within Normal Limits

Answer

Without Neurological Loss

Answer

Well-Nourished Level

Answer

Wound Noted on Left

Question 3

During assessment, a nurse identifies that a client has a nursing problem that was not identified on the care plan. According to CNO accountability standards, what should the nurse do?

Accepted Answer

Update the plan of care and communicate the finding to the healthcare team

Answer

Ignore it if it is not life-threatening

Answer

Wait until the next shift to report it

Answer

Only document it in a personal notebook

Question 4

A nurse assesses a client's pedal pulses and rates them as 1+. What does this indicate?

Accepted Answer

Diminished pulses that are weak and barely palpable

Answer

Bounding, strong pulses

Answer

Absent pulses

Answer

Normal pulse strength

Question 5

A nurse is caring for a client who speaks limited English. How should the nurse best conduct the health assessment?

Accepted Answer

Use a trained professional interpreter to ensure accurate communication

Answer

Use medical jargon and assume the client understands

Answer

Ask a family member to translate all clinical questions

Answer

Skip the subjective assessment and rely only on objective data

Question 6

When performing a nutritional assessment on an older adult client, which tool is commonly used to screen for malnutrition risk?

Accepted Answer

Mini Nutritional Assessment (MNA)

Answer

APGAR score

Answer

CAGE questionnaire

Answer

Braden Scale