RPN Client Assessment and Planning 3 — Questions and Answers
Question 1: When planning care for a client with a newly diagnosed pressure injury (Stage II), which outcome is MOST appropriate?
- Client will verbalize understanding of wound care by discharge
- Wound will show signs of healing within 2 weeks (Correct answer)
- Client will be repositioned every 4 hours
- Family will perform dressing changes independently
Correct answer: Wound will show signs of healing within 2 weeks
A measurable outcome focused on wound healing within a realistic timeframe aligns with Stage II pressure injury management.
Question 2: A client's care plan identifies a nursing diagnosis of 'Deficient fluid volume related to vomiting.' Which assessment finding BEST supports this diagnosis?
- Blood pressure 130/80 mmHg
- Urine specific gravity 1.030 (Correct answer)
- Skin turgor with immediate recoil
- Moist mucous membranes
Correct answer: Urine specific gravity 1.030
A urine specific gravity of 1.030 indicates concentrated urine, a sign of dehydration consistent with deficient fluid volume.
Question 3: Which data is considered OBJECTIVE during a client assessment?
- Client reports feeling anxious
- Client states 'I have a headache'
- Blood pressure reading of 158/94 mmHg (Correct answer)
- Client describes nausea after eating
Correct answer: Blood pressure reading of 158/94 mmHg
Objective data is measurable and observable by the nurse, such as vital sign readings, unlike subjective data reported by the client.
Question 4: During shift handoff, the oncoming RPN reviews a client's care plan and notes an outdated nursing diagnosis. The BEST action is to:
- Leave it unchanged to maintain consistency
- Delete it and add a new one without documentation
- Revise the care plan to reflect the client's current status (Correct answer)
- Ask the physician to update the diagnosis
Correct answer: Revise the care plan to reflect the client's current status
Care plans must be continuously updated to reflect current assessment findings and evolving client needs.
Question 5: A client admitted for chest pain has an irregularly irregular heart rhythm on ECG. The RPN should:
- Assume it is an artifact and continue monitoring
- Assess the client, document findings, and notify the physician (Correct answer)
- Administer a PRN antiarrhythmic medication
- Reapply ECG leads and retake the reading
Correct answer: Assess the client, document findings, and notify the physician
An irregularly irregular rhythm may indicate atrial fibrillation; the RPN must assess the client and report findings to the physician.
Question 6: Which assessment technique is used to detect fluid in the lungs (consolidation)?
- Inspection
- Palpation
- Percussion
- Auscultation (Correct answer)
Correct answer: Auscultation
Auscultation of lung sounds detects crackles and decreased breath sounds associated with fluid consolidation.
Question 7: The RPN is developing a care plan for a post-surgical client. Which component of the nursing diagnosis identifies the cause of the problem?
- Problem statement
- Related factor (etiology) (Correct answer)
- Defining characteristics
- Expected outcome
Correct answer: Related factor (etiology)
The related factor (etiology) component of a nursing diagnosis identifies what is causing or contributing to the problem.
RPN Client Assessment and Planning 3
When planning care for a client with a newly diagnosed pressure injury (Stage II), which outcome is MOST appropriate?