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

Tachypnea with accessory muscle use indicates significant respiratory distress and demands immediate nursing intervention.

Question 2

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

Accepted Answer

Within Normal Limits

Answer

'WNL' stands for Within Normal Limits and is used in nursing documentation to indicate that a finding is within expected parameters.

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

CNO standards require nurses to update the care plan and communicate new findings to ensure continuity and safety of care.

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

A 1+ pulse rating indicates a weak, barely palpable pulse, suggesting reduced peripheral arterial perfusion.

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

A trained professional interpreter ensures accurate, confidential, and culturally appropriate communication during assessments.

CNO - College of Nurses of Ontario Practice Test

CNO - College of Nurses of Ontario Practice Test

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