All ATI Sample Questions

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (select all that apply.) -"Are you experiencing difficulty breathing?" -"How long has the lump been on your neck?" -"Is the lump causing you discomfort?" -"Are you having difficulty swallowing?" -"Have you started taking new medication?"

-"Are you experiencing difficulty breathing?" -"How long has the lump been on your neck?" -"Is the lump causing you discomfort?" -"Are you having difficulty swallowing?"

A nurse is preparing to perform palpation on a client's knees. In which order should the nurse perform the following steps? -Assist the client to a sitting position with the legs dangling at the edge of the examination table -Follow the lower edge of the patella and locate the tibiofemoral joint -Palpate the hollows on either side of the patella with the thumbs. -Palpate the tibiofemoral joint where the femur and tibia meet -Palpate the quadriceps muscle above the knee

-Assist the client to a sitting position with the legs dangling at the edge of the examination table -Palpate the quadriceps muscle above the knee -Palpate the hollows on either side of the patella with the thumbs. -Follow the lower edge of the patella and locate the tibiofemoral joint -Palpate the tibiofemoral joint where the femur and tibia meet

A nurse is caring for a client who had a suspected stroke. Which of the following actions should the nurse take? (select all that apply.) -Make the client NPO. -Assess the client's orientation. -Check cranial nerves I, II, and V. -Inspect client's muscular symmetry. -Obtain the client's vital signs.

-Make the client NPO. -Assess the client's orientation. -Obtain the client's vital signs

A nurse is preparing to perform light palpation of a client's abdomen. In what order should the nurse perform the following steps? -Use the finger pads of one hand to palpate. -Place the client's arms at their sides. -Depress the client's abdomen using a dipping motion. -Move fingers across the client's abdomen moving clockwise. -Palpate painful areas.

-Place the client's arms at their sides. -Use the finger pads of one hand to palpate. -Depress the client's abdomen using a dipping motion. -Move fingers across the client's abdomen moving clockwise. -Palpate painful areas.

A nurse is conducting a health history interview with a client about their urinary system. The nurse should recognize that which of the following client reports could indicate the presence of declining kidney function? (select all that apply) -Recent weight gain -Hematuria -Shortness of breath -Swelling in the ankles -Difficulty starting a urine stream

-Recent weight gain -Shortness of breath -Swelling in the ankles

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the clients left arm. Which of the following terms should the nurse use to describe this involuntary movement? A.Fasciculation B.Spasticity C.Tic D.Myoclonus

A.Fasciculation

A nurse is preparing to inspect the umbilicus of a client's abdomen. Which of the following findings should the nurse identify as an unexpected finding? A.Swelling B.Mole C.Extraversion D.Scar

A.Swelling

A nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough. The client states they identify as transgender. Which of the following questions should the nurse ask? A."How does your family feel about your gender identity?" B."What pronouns do you use?" C."When did you transition?" D."Are you planning to ever have surgery to change your biological sex?"

B."What pronouns do you use?"

A nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend? A.500 to 1,000 mg daily B.1,000 to 1,200 mg daily C.1,500 to 2,000 mg daily D.2,000 to 2,200 mg daily

B.1,000 to 1,200 mg daily

A nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amounts should he nurse recommend? A.500 IU daily B.800 IU daily C.1,500 IU daily D.1,800 IU daily

B.800 IU daily

A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take? A.Assess the client's blood glucose level B.Ask the client for additional information regarding the management of their diabetes C.Encourage the client to join a diabetic support group D.Provide education for the client on the management of diabetes

B.Ask the client for additional information regarding the management of their diabetes

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report t the provider? A.Areolas are oval-shaped B.Scaley skin at the border of one areola C.Small bumps visible on each areola D.Areolas have darker pigment than the surrounding skin

B.Scaley skin at the border of one areola

A nurse is preparing to assess a client's genitalia. Which of the following actions should the nurse plan to take? A.Ensure the client has a full bladder B.Use a firm, deliberate touch when palpating C.Apply sterile gloves prior to touching the genitalia D.Remove the drape from the lower half of the clients body

B.Use a firm, deliberate touch when palpating

A nurse is preparing to assist with a prostate examination. Which of the following actions should the nurse plan to take? A.Supply sterile gloves for the provider B.Provide the supplies for a specimen culture C.Position the client standing, facing the examination table D.Darken the lighting in the room

C.Position the client standing, facing the examination table

A nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is an expected variation for this client? A.Yellowing of the hard palate B.Red spots on the hard palate C.White patches on the tongue D.Darkening of the mucosa

D.Darkening of the mucosa

A nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take? A.Perform the assessment from the toes to the head B.Assess the extremities from distal to proximal C.Perform passive range of motion before active range-of motion movements. D.Inspect for symmetry on both sides of the body.

D.Inspect for symmetry on both sides of the body.

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding? A.Skin is deeply pigmented B.Presence of plaques C.Fixation of tissue during arm movement D.Skin has a uniform consistency

D.Skin has a uniform consistency

A nurse is caring for a client who has a stage 1 pressure injury. which of the following formation should the nurse include when documenting the characteristics of the wound?( select all that apply) Location of the pressure injury. Size of the injury in centimeters. Depth of the injury in centimeters. Color and odor of drainage from the wound. Integrity of the skin surrounding the wound.

Location of the pressure injury. Size of the injury in centimeters. Integrity of the skin surrounding the wound.

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following question should the nurse ask? (select all that apply) "Are you experiencing abdominal pain?" "Do you take any medication?" "Have you noticed a change in your appetite?" "When was your last bowel movement?" "Have you had any changes in your urinary output?"

"Are you experiencing abdominal pain?" "Do you take any medication?" "Have you noticed a change in your appetite?" "When was your last bowel movement?"

A nurse is conducting a health history interview. Which of the following questions should the nurse ask when gathering information about a client's cardiac and peripheral vascular system?(select all that apply) "Have you experienced any chest pain, tightness or discomfort?" "Have you had any changes in your appetite or food intolerances?" "Have you noticed any swelling in your hands, feet or ankles?" "Do you feel short of breath during the day or while sleeping?" "When did you have have a screening test for tuberculosis?"

"Have you experienced any chest pain, tightness or discomfort?" "Have you noticed any swelling in your hands, feet or ankles?" "Do you feel short of breath during the day or while sleeping?"

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following statements indicate an understanding of the teaching? (select all that apply) "I am going to start walking several times a week." "I plan to join a support group to help me stop smoking." "If my HDL cholesterol levels are high, it can hurt my heart." "I will be sure to have my blood pressure checked at least every year." "Eating more low-fiber foods and processed carbohydrates will make my heart healthier."

"I am going to start walking several times a week." "I plan to join a support group to help me stop smoking." "I will be sure to have my blood pressure checked at least every year."

A nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (select all that apply) "Smoking is linked to various forms of cancer." "there are no risks associated with exposure to secondhand smoke." "It might take several attempts to finally stop smoking." "Smoking will cause you to die years earlier than if you didn't smoke." "There are pharmacologic therapies that can help a person stop smoking."

"Smoking is linked to various forms of cancer." "It might take several attempts to finally stop smoking." "There are pharmacologic therapies that can help a person stop smoking."

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history? (select all that apply) -"Have you ever had breast disease?" -"Have you experienced breast trauma?" -"Have you had breast surgery?" -"Do you perform breast examinations?" -"Has anyone in your family had breast cancer?"

-"Have you ever had breast disease?" -"Have you experienced breast trauma?" -"Have you had breast surgery?" -"Do you perform breast examinations?"

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (select all that apply) -"Have you had trouble hearing?" -"Do you ever lose your balance?" -"Have you ever used hearing aids?" -"Do you have ringing in your ears?" -"Do you have problems with nasal drainage?"

-"Have you had trouble hearing?" -"Do you ever lose your balance?" -"Have you ever used hearing aids?" -"Do you have ringing in your ears?"

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health? (select all that apply) -Ask the client to describe the process for breast self-examination at the end of the teaching -Document instructions provided in the client's medical record -Provide the client with information about the human papilloma virus (HPV) vaccine -Review recommendations for mammography based on risk with the client -Begin the teaching by listing national guidelines for breast screening

-Ask the client to describe the process for breast self-examination at the end of the teaching -Document instructions provided in the client's medical record -Review recommendations for mammography based on risk with the client

A nurse is preparing to perform palpation of a client's shoulder. In what order should the nurse perform the following steps? -Face the client and palpate along the clavicle -From the back, palpate the greater tubercle of the humerus -From the back, palpate the scapula -Face the client and palpate the acromioclaviclar joint

-Face the client and palpate along the clavicle -Face the client and palpate the acromioclaviclar joint -From the back, palpate the scapula -From the back, palpate the greater tubercle of the humerus

A nurse is preparing to assess a client for the presence of a hernia. Which of the following areas should the nurse plan to inspect? (select all that apply) -Femoral area -Inguinal area -Rectal area -Length of the shaft -The circumference of the glans

-Femoral area -Inguinal area

A nurse is inspecting the genitals of an adult male client. Which of the following should the nurse identify as expected findings? (select all that apply) -Visible dorsal vein on the underside of the penile shaft -Bilateral pea-sized (1 cm), soft testes -Meatus located on the dorsal side of the glans -Absence of pubic hair on the penile shaft -Testes that are easily moveable during palpation

-Visible dorsal vein on the underside of the penile shaft -Absence of pubic hair on the penile shaft -Testes that are easily moveable during palpation

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer? (select all that apply) -dilation of the hair follicles -bilateral tissue enlargement -nipple retraction -a small bulging nodule lateral to one breast -palpable montgomery glands

-dilation of the hair follicles -nipple retraction -a small bulging nodule lateral to one breast

A nurse is caring for an older adult client who has an enlarged prostate and reports difficulty voiding. Which of the following action should the nurse take? (select all that apply) -perform a bladder scan within 60 min of the client voiding -ensure that the client's intake is significantly greater than output -inspect the client's suprapubic area for distention -notify the provider if the bladder scan residual volume is greater than 100 mL -ask the client if they are experiencing pain or a burning sensation when voiding

-inspect the client's suprapubic area for distention -notify the provider if the bladder scan residual volume is greater than 100 mL -ask the client if they are experiencing pain or a burning sensation when voiding

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (select all that apply) -oval white patches in the client's hair -a lesion on the client's scalp -protrusion of the client's head -edema around the client's eyes -protrusion of the client's mastoid bone

-oval white patches in the client's hair -a lesion on the client's scalp -protrusion of the client's head -edema around the client's eyes

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations performed on a regular basis? (select all that apply) -vision screening every year -hearing test every 5 years -dental examination every 6 months -skin cancer screening every 2 years -neurological check every 3 months

-vision screening every year -dental examination every 6 months

A nurse is providing education to a female client who has expressed a desire to use a natural method of contraception. Which of the following methods should the nurse recommend? (select all that apply) -condoms -withdrawal -fertility tracking with periodic abstinence -spermicidal sponge -tubal ligation

-withdrawal -fertility tracking with periodic abstinence

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to perform the steps of breast self-examination? (move the steps into all the box on the right, placing them in order of performance. use all the steps) 1. Instruct the breasts for changes in shape, color, or contour 2. Lie down and prepare to palpate breast with the pads of the second, third, and fourth fingers 3. Look at the breast in front of a mirror with hands placed on hips 4. Inspect the nipples for a rash or drainage 5. Palpate each breast from the outer edge, moving from top to bottom across the breast

3. Look at the breast in front of a mirror with hands placed on hips 1. Instruct the breasts for changes in shape, color, or contour 4. Inspect the nipples for a rash or drainage 2. Lie down and prepare to palpate breast with the pads of the second, third, and fourth fingers 5. Palpate each breast from the outer edge, moving from top to bottom across the breast

A nurse is preparing to assess a clients conjunctiva. Identify the sequence the nurse should follow when taking the following actions. (move the steps into the box on the right, placing them in the selected order of performance. use all the steps.) 1.Instruct the client to look up. 2.Gently pull the client's skin down to the top edge of the bony orbital rim. 3.Apply examination gloves. 4.Place the thumbs below each of the client's lower eyelids. 5.Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

3.Apply examination gloves. 1.Instruct the client to look up. 4.Place the thumbs below each of the client's lower eyelids. 2.Gently pull the client's skin down to the top edge of the bony orbital rim. 5.Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes. 2. Ask the client if they detect tenderness or pain. 3.Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses 4.Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses 5.Apply firm, upward pressure and ask the client if they detect tenderness or pain.

3.Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses 1. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes. 2. Ask the client if they detect tenderness or pain. 4.Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses 5.Apply firm, upward pressure and ask the client if they detect tenderness or pain.

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? 1.Assist the client to stand and obtain their blood pressure 2.Keep the cuff in place and assist the client to a seated position 3.take the clients blood pressure in the supine position 4.place the client in a supine position and allow them to rest 5.take the clients blood pressure in a seated position

4.place the client in a supine position and allow them to rest 3.take the clients blood pressure in the supine position 2.Keep the cuff in place and assist the client to a seated position 5.take the clients blood pressure in a seated position 1.Assist the client to stand and obtain their blood pressure

A nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A."A 55-year-old client should receive mammography screenings at least every 2 years." B."Clients can discontinue routine mammography screenings when they are 65 years old." C."Clients should begin routine mammography screenings when they are 35 years old." D."A 45-year old client should receive mammography screenings at least every 5 years."

A."A 55-year-old client should receive mammography screenings at least every 2 years."

A nurse is providing teaching about the prevention of sexually transmitted infections (STIs) to a 19-year-old client who is sexually active and reports having multiple partners. Which of the following client responses demonstrates an understanding of the teaching? A."I should plan on getting tested each year for sexually transmitted infections." B."Taking my birth control pills daily will prevent me from getting an infection." C."Because I am at a low risk for HIV, I only need to get tested every other year." D."Since I got the Hepatitis B vaccine, I am protected from sexually transmitted infections."

A."I should plan on getting tested each year for sexually transmitted infections."

A nurse is reviewing breast self-examination techniques with a client. Which of the following client statements indicates an understanding of the techniques? A."I will use circular motions to feel the texture of my breast tissue." B."I will use the palmar surface of my hands to perform breast palpation." C."I will lie down and put one hand behind my head to examine the breast on the opposite side of my body." D."I will examine my breasts after bathing and driving throughly."

A."I will use circular motions to feel the texture of my breast tissue."

A nurse is performing range-of-motion exercises on a client's feet. The nurse should provide which of the following instructions to the client to assess plantar flexion of the feet? A."Point your toes toward the floor." B."Turn the soles of your feet out, away from the body." C."Point your toes up toward your nose." D."Turn the bottoms of your feet in, toward the midline."

A."Point your toes toward the floor."

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make? A."The penlight will allow me to look at the pulses in your neck." B."The penlight will allow me to locate your pedal pulse." C."The penlight will be used to check for skin turgor." D.""The penlight will be used to evaluate the effort you use to breathe."

A."The penlight will allow me to look at the pulses in your neck."

A nurse is providing education to a male client about health promotion screenings. Which of the following information should the nurse include in the teaching? A.A digital rectal examination can detect enlargement of the prostate gland B.The prostate-specific antigen (PSA) test evaluates semen for the presence of cancer cells C.Testicular self-examination should be performed when the client is sitting in a cool environment D.A client who has an average risk for colorectal cancer should have a colonoscopy every 2 years

A.A digital rectal examination can detect enlargement of the prostate gland

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as unexpected variation? A.An adolescent who has an S3 heart sound B.An older adult who has a heart rate of 40/min C.A young adult who has an irregular apical pulse D.A middle adult who has a murmur

A.An adolescent who has an S3 heart sound

A nurse in the emergency department has received report on a child who has a laceration to the right calf. which of the following steps of the nursing process should the nurse perform first? A.Assessment B.Analysis C.Evaluation D.Planning

A.Assessment

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider? A.Capillary refill of 3 seconds B.+2 radial pulse C.Fingernail with 160 curve D.Oxygen saturation 98%

A.Capillary refill of 3 seconds

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect? A.Defined reddened area of the sclera B.Drooping of the eyelid C.Cloudy pupil D.Bulging eyes

A.Defined reddened area of the sclera

A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect? A.Dilated veins B.Stretch Marks C.Purple Striae D.Rash

A.Dilated veins

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding? A.Encounter B.Vital Signs C.Patient information D.Allergies and home medications

A.Encounter

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? A.Implementation B.Evaluation C.Analysis D.Planning

A.Implementation

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? A.Limit elevation of the head of the bed to 30 or less B.Apply baby powder and massage the area every 2 hr C.Reposition the client every 4 hr D.Ensure that the client uses a donut-shaped cushion when sitting in a chair

A.Limit elevation of the head of the bed to 30 or less

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? A.Pale mucosa B.Bright red mucosa C.Green discharge D.Yellow Discharge

A.Pale mucosa

A nurse is preparing to assist the provider with an assessment of a female client's genitourinary system. Which of the following actions should the nurse plan to take? A.Position the client supine with the head of the bed elevated B.Avoid conversation while the provider is performing the assessment C.Instruct the client to position their knees inward D.Position the client's arms above their head

A.Position the client supine with the head of the bed elevated

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which of the following quadrants should the nurse listen to first? A.Right lower quadrant B.Left lower quadrant C.Right upper quadrant D.Left upper quadrant

A.Right lower quadrant

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting? A.Subjective B.Probing C.Objective D.Observation

A.Subjective

A nurse is assessing a clients respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? A.Tachypnea B.Bradypnea C.Apnea D.Hyperventilation

A.Tachypnea

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms. How should the nurse interpret this finding? A.The client might have a blood clot B.The client might have an infection C.The client is experiencing complications of kidney failure D.The clients blood oxygen levels are lower than expected.

A.The client might have a blood clot

A nurse is conducting a health history interview with a client. Which of the following is accurate about a directive interview technique? A.This technique consists of mostly closed-ended questions. B.This technique enables the client to control the pace of the interview. C.This technique is used to gather general information about a clients condition. D.This technique is effective for determining a client's emotional responses.

A.This technique consists of mostly closed-ended questions.

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect? A.White patches on the tongues B.Beeft red tongue C.Petechiae on hard palate D.Overgrowth of gum tissue

A.White patches on the tongues

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use? A.penlight B.Otoscope with a pneumatic bulb attachment C.Wide-tipped speculum D.Tongue blade

A.penlight

A nurse is collecting a health history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take? A.speak directly to the client throughout the interview B.Ensure the interpreter is positioned behind the client for privacy C.Ask the interpreter to summarize a group of questions for the client D.Use accurate medical terminology when gathering information

A.speak directly to the client throughout the interview

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse the nurse plan to take (select all that apply) Auscultate the apical pulse Ask the client if they experience shortness of breath Check the color of the clients skin Auscultate bowel motility Inspect the extremities for the presence of edema

Auscultate the apical pulse Ask the client if they experience shortness of breath Check the color of the clients skin Inspect the extremities for the presence of edema

A nurse is collecting data from a client about their skin and nails. Which of the following statements by the client should the nurse identify as needing further assessment? A."When I was a child, I developed a rash after taking amoxicillin." B."I noticed that my fingernails have changed recently." C."I used to take baths, but I recently switched to showering." D."In my family, one cousin has basal cell carcinoma."

B."I noticed that my fingernails have changed recently."

A nurse is assessing flexion of a client's elbows. The nurse should provide which of the following instructions to the client? A."Start with your arms straight out in front of you with palms facing the floor then twist at your elbows so your palms are facing up toward the ceiling." B."Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulder." C."Start with your arms straight out in front of you with palms facing the ceiling then twist at your elbows so your palms are facing down toward the floor." D."Start with your elbows bent and fingers at your shoulders then straighten your arms out in front of you."

B."Start with your arms straight out in front of you then bend your elbows up and bring your fingers toward your shoulder."

A nurse is providing education to a young adult client about the human papillomavirus (HPV) vaccine. Which of the following information should the nurse include in the teaching? A.The HPV vaccine is only recommended for female clients B.An HPV infection can lead to the development of cancer C.The HPV vaccine should be administered before age 18 to be effective D.Immunization to prevent an HPV infection requires a single injection

B.An HPV infection can lead to the development of cancer

A nurse is inserting a urinary catheter for a female adolescent. Which of the following findings should the nurse report to the provider? A.A membrane at the vaginal opening B.An area of tenderness on the labia majora C.Lack of pubic hair on the medial thigh D.Labia minora is a darker skin tone than overall coloring

B.An area of tenderness on the labia majora

A nurse is providing a bed bath for an older adult client who is immobile. Which of the following findings should the nurse report to the provider? A.A pendulous scrotal sac B.An inability to retract the foreskin C.Sparse pubic hair D.Left testicle is positioned lower than the right one

B.An inability to retract the foreskin

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which of the following ethical principles is the client using? A.Nonmaleficence B.Autonomy C.Justice D.Fidelity

B.Autonomy

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify which of the following findings indicates the client might have a skull fracture? A.Edema around the ear B.Bloody drainage C.Yellow drainage D.Crusted skin

B.Bloody drainage

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing? A.Thoracic breathing B.Cheyne-Stokes breathing C.Bradypnea D.Kaussmaul's breathing

B.Cheyne-Stokes breathing

A Nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following information should the nurse include? A.Fiber can be found in most dairy products B.Fiber allows larger stool to soften and pass easier C.Fiber decreases peristalsis to prevent diarrhea D.Fiber promotes the growth of good bacteria in the intestinal tract

B.Fiber allows larger stool to soften and pass easier

A nurse is assessing a clients jugluar veins and carotid arteries. The nurse should assist the client into which of the following positions? A.Place the client in high-Fowler position B.Have the client lay supine with the head of their bed at a 45 angle C.Have the client seated with their chin touching their chest D.Place the client in a left lateral position

B.Have the client lay supine with the head of their bed at a 45 angle

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement? A.A supernumerary nipple B.Infection C.Increased adipose tissue D.Psychotropic medication use

B.Infection

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment? A.lateral to the umbilicus B.Inferior to the collar bone C.Dorsal side of the hand D.Anterior aspect of the neck

B.Inferior to the collar bone

A nurse is preparing to assess a client's abdomen. Upon palpation, which of the following findings should the nurse report to the provider? A.Nontender B.Involuntary rigidity C.Relaxed muscles D.Adipose tissue

B.Involuntary rigidity

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include? A.Increase intake of red meat B.Limit sodium intake to less than 3,000 mg/day C.Increase intake of food high in trans fat D.Drink whole milk

B.Limit sodium intake to less than 3,000 mg/day

A nurse is caring for a male client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause of this condition? A.Presence of the BRCA1 gene B.Medication adverse effects C.Deceased estrogen levels D.Decreased thyroid hormone levels

B.Medication adverse effects

A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? A.Document client data. B.Provide an opportunity for the client to ask questions C.Explain the reason fro the interview D.Greet client with an introduction

B.Provide an opportunity for the client to ask questions

A nurse is inspecting a client's rectal area and notes the presence of bulging red tissue that encompasses the entire anal opening. Which of the following should the nurse suspect? A.Anal fissure B.Rectal Prolapse C.External hemorrhoid D.Pilonidal sinus

B.Rectal Prolapse

A nurse is performing a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading fine print. In which of the following sections of the clients electronic health record (EHR) should the nurse document this finding? A.Vital Signs B.Review of systems C.Allergies and home medications D.Patient information

B.Review of systems

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? A.Abnormal sounds made by tapping on the clients skin B.Skin temperature, moisture, and abnormalities C.Heart sounds, lung sounds, and bowel sounds D.The clients cleanliness and grooming.

B.Skin temperature, moisture, and abnormalities

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? A.Bradycardia B.Tachycardia C.Atrial fibrillation D.Pulse deficit

B.Tachycardia

A nurse assesses a clients respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? A.The client has been a chronic smoker for 10 years B.The client takes a narcotic pain medication for chronic pain C.The client reports anxiety due to being in the hospital D.The client has a history of anemia

B.The client takes a narcotic pain medication for chronic pain

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? A.The nurse asks the client to cough before beginning the auscultation B.The nurse is auscultating through the clients gown C.The nurse placed the stethoscope on the intercostal spaces D.The nurse moves down the chest in a ladder sequence

B.The nurse is auscultating through the clients gown

A nurse is evaluating assessment findings of a clients skin. The nurse should identify that which of the following findings is associated with a possible infection? A.Wheals B.Vesicles C.Papules D.Bullas

B.Vesicles

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider? A.Skin tags on the neck B.Yellow discoloration of the palms C.Brown birthmark on the thigh D.Absent tenting of the skin

B.Yellow discoloration of the palms

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? A.Ptosis of an eyelid B.Yellow sclera C.Edema of the eyelids D.Reddened conjunctiva

B.Yellow sclera

A nurse is completing documentation in a clients medical record. Which of the following actions should the nurse take? A.document that the nurse believes the client is feeling better B.record the clients most recent assessment results C.If there are no changes to the clients status, record "status unchanged" in the medical record D.after making a documentation error, leave it as is begin a new entry

B.record the clients most recent assessment results

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease? A.parent who experienced a pulmonary embolism B.sibling who has hypertension C.cousin who has diabetes mellitus D. child who has epilepsy

B.sibling who has hypertension

A nurse is documenting a client's vital signs in the medical record following a general survey. which of the following entries should the nurse place in the record? A.Temperature 95F, client is hypothermic B.Pulse rate indicates tachycardia C. Oxygen saturation 96% on oxygen 2L/min via nasal cannula D.Blood Pressure 108/65 mmHg in left arm

C. Oxygen saturation 96% on oxygen 2L/min via nasal cannula

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A."A client using thoracic breathing is experiencing a lack of oxygen" B."A pulse oximeter reading of less than 95% indicates respiratory distress" C."Clubbing of the fingers indicates a chronic state of impaired perfusion" D."A pinkish hue on the cheeks of a client who is light-skinned indicates they are struggling to breath."

C."Clubbing of the fingers indicates a chronic state of impaired perfusion"

A nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse? A."The bruise on my leg is from running into the base of a chair." B."I'm sleeping better since I gave up caffeine in the afternoon." C."For some reason I have been experiencing falls." D."I no longer have back pain since I started walking 2 miles every day."

C."For some reason I have been experiencing falls."

A nurse is collecting a health history from a client. Which of the following client statements requires further investigation? A."I urinate a lot when I get up in the morning." B."I have a bowel movement every morning after breakfast." C."I have noticed that it burns when I urinate." D."I empty my bladder several times a day."

C."I have noticed that it burns when I urinate."

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicates an understanding of the teaching? A."Exposing these areas to tanning bed twice a month will decrease the outbreaks." B."Opening the acne lesions will make them drain and go away faster." C."I should was the areas frequently with warm water and soap." D."Keeping the skin moist with oil-based creams will prevent acne outbreaks."

C."I should was the areas frequently with warm water and soap."

A nurse is assessing the range of motion of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers? A."Bend the thumb in toward the palm of the hand and then move it back out." B."Make a fist and the straighten the fingers." C."Spread the fingers apart and the move them back together." D."Bend the thumb to touch the tip of each finger."

C."Spread the fingers apart and the move them back together."

A nurse is discussing a client's tobacco usage during a health history interview. Which of the following questions should the nurse ask to maintain client rapport? A."You are worried about the amount that you smoke, right?" B."Did you know that smoking can lead to a decreased lung recoil, which results in hyperinflation and dyspnea?" C."Would you like any information on smoking cessation?" D."Why do you think you are smoking so much?"

C."Would you like any information on smoking cessation?"

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make? A."its just a small umber of people that get the flu from receiving the vaccine" B."Call your provider immediately if you have any flu-like symptoms after receiving the vaccine." C."You should make every effort to receive a flu vaccine every year." D."The vaccine becomes effective immediately after the injection."

C."You should make every effort to receive a flu vaccine every year."

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple? A.A client reports recent serosanguinous nipple discharge B.A client reports that one nipple has begun to point in a different direction C.A client's nipple has remained inverted since childhood D.A client's nipple has a small crust present on the tip

C.A client's nipple has remained inverted since childhood

A nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take? A.Apply heat therapy after the first 24 hr following the injury. B.Place an ice pack directly on the injured area. C.Apply compression to the injured area of the extremity. D.Encourage the client to use the extremity as much as possible.

C.Apply compression to the injured area of the extremity.

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? A.White patches on the tongue B.Bleeding of the gums C.Beefy red tongue D.Petechiae of the hard palate

C.Beefy red tongue

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client of reduce their stress? A.Instruct the client to vary the time they go to sleep each night B.Have the client check their BP daily C.Discuss the benefits of medications with the client D.Have the client limit their exercise program until the stress has decreased

C.Discuss the benefits of medications with the client

A nurse is caring for a client who is having difficulty breath. Which of the following actions should the nurse take first? A.Instruct the client to deep breath and cough B.Provide the client with an incentive spirometer C.Elevate the head of the client's bed D.Reassess by auscultating the clients lungs

C.Elevate the head of the client's bed

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. which of the following actions should the nurse plan to take? A.Have an informal conversation with the client before beginning observation of the client. B.Complete all focused assessments prior to formulating thoughts regarding the client's general health status C.Engage in active listening with the client and allow the client to express concerns early in the assessment process D.Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible

C.Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A.Measure the client's shoe heel height with a tape measure and deduct this amount B.Have the client gently lift their chin and look toward the ceiling. C.Ensure the clients feet are in contact with the wall or measuring pole D.Skip the height measurement if the client cannot stand

C.Ensure the clients feet are in contact with the wall or measuring pole

A nurse is performing range-of-motion exercises on a client's hips. The nurse is assessing which of the following motions by instructing the client to bend the knee and bring it up toward the chest? A.External rotation of the hip B.Adduction of the hip. C.Flexion of the hip. D.Hyperextension of the hip

C.Flexion of the hip.

A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus? A.Hypoactive bowel sounds B.Absent bowel sounds C.Hyperactive bowel sounds D.Normoactive bowel sounds

C.Hyperactive bowel sounds

A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? A.Limited access to convenience foods B.A park available within walking distance from the client's residence C.Limited access to a pharmacy D.A neighborhood population that has a high rate of obesity and smoking

C.Limited access to a pharmacy

A nurse is teaching a group of female clients about breast self-awareness. Which of the following instructions should the nurse include? A.Breasts are the least tender during the first 3 days of the menstrual cycle B.Females can discontinue breast self-examination after menopause C.Menstruating females should examine their breasts about 5 days after their menstrual cycle begins D.Benign breast nodules are less prominent during the premenstrual phase

C.Menstruating females should examine their breasts about 5 days after their menstrual cycle begins

A nurse is caring for a client who has a foot ulcer. Which of the following finding should the nurse identify as consistent with peripheral venous disease? A.Loss of hair on the lower leg B.Cool skin temperature in the lower leg C.Palpable dorsalis pedal pulse D.Regular, even would borders

C.Palpable dorsalis pedal pulse

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? A.use the soft end of a cotton swab over the abdomen B.Auscultate the tender areas of the abdomen through clothing C.Palpate the tender areas of the abdomen last. D.Use a two-point discrimination with a paper clip on the clients abdomen

C.Palpate the tender areas of the abdomen last.

A nurse is teaching a client about the purpose of probiotics and incorporating them in their diet. Which of the following information should the nurse include? A.Probiotics increase peristalsis to prevent constipation B.Probiotics allow larger stool to soften to pass C.Probiotics promote the growth of good bacteria in the client's intestinal tract D.Probiotics remove fats and waste products from the body

C.Probiotics promote the growth of good bacteria in the client's intestinal tract

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? A.Tell the client that everything will be just fine B.Change the subject while the client is discussing their feelings C.Put themselves in the clients situation to understand the clients anxiety D.Tell the client that it is wrong to be crying over this situation

C.Put themselves in the clients situation to understand the clients anxiety

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading? A.Hypertension B.Fever C.Recent scan with contract dye D.Thin, brittle nails

C.Recent scan with contract dye

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the clients breasts? A.Standing upright with their arms held straight out to their sides B.Bending over at the waist with hands reaching toward the toes C.Sitting straight up with arms relaxed and close to the body D.Lying supine with hands clasped together at the umbilicus

C.Sitting straight up with arms relaxed and close to the body

A nurse is examining a lesion on a clients back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion? A.smooth, defined border B.Uniform color C.Size of a pencil eraser D.Symmetrical appearance

C.Size of a pencil eraser

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider? A.yellowed nail color B.White horizontal lines C.Spongy nail base D.Capillary refill 2 seconds

C.Spongy nail base

A nurse is assessing an older adult while they walk. Which of the following findings should the nurse report to the provider? A.The client walks with small steps B.The client walks with their legs spread out C.The client walks with a shuffling gait D.The client walks with a forward-bent posture

C.The client walks with a shuffling gait

A nurse is performing a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions? A.Infection B.Cancer C.Thyroid disorder D.Chest disorder

C.Thyroid disorder

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? A.Outer layer of the eyeball B.Mucous membrane that lines the eyeball C.Transparent layer that covers the iris and pupil D.Colored portion in the center of the eye

C.Transparent layer that covers the iris and pupil

a nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend? A.increase the frequency of bathing B.use a dehumidifier to reduce air moisture C.apply an alcohol-free lotion D.cover the dry areas with a thin coating of powder

C.apply an alcohol-free lotion

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse? A.ask the client to clarify a statement B.Ask the client open-ended questions C.maintain a fair distance between self and client D.state the name and provide credentials upon entering the clients room

C.maintain a fair distance between self and client

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (select all that apply) Coarse grating tone Intermittent popping or bubbling sound Heard on inspiration and expiration Snoring sound on expiration Pain with breathing

Coarse grating tone Heard on inspiration and expiration Pain with breathing

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? A.close the examination room door but do not pull the curtain in the examination room B.remain in the clients room while the client is getting undressed C.ask the client if they would like to empty their bladder and bowel before the physical examination begins D. Do not expose any more of the clients body than require at a time

D. Do not expose any more of the clients body than require at a time

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? A.Enlist aid of the clients school-aged child to interpret for the nurse and the client B.Ask the clients best friend tin interpret for the nurse and client C.Use jokes and laughter to make the client feel more at ease D. request assistance from an interpreter during the assessment

D. request assistance from an interpreter during the assessment

A nurse is providing teaching to a client about health promotion to prevent constipation. Which of the following instructions should the nurse include? A."Limit vegetables to 10% of your daily intake." B."Drink 32 ounces of water per day." C."Eliminate legumes from your diet." D."Consume foods that are high in whole grains."

D."Consume foods that are high in whole grains."

A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? A."I had a rash from poison ivy on my arms last week, but it's gone now." B."I wear a hearing aid." C."I had a negative tuberculosis screening test last month." D."I have a cough."

D."I have a cough."

A nurse is teaching a young adult about the risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching? A."The fact that I have moles increases my risk for developing melanoma." B."My cousin had squamous cell carcinoma, which increases my risk for melanoma." C."Having a light complexion decreases my risk for developing melanoma." D."The blistering sunburns I had as a child increase my risk for melanoma as an adult."

D."The blistering sunburns I had as a child increase my risk for melanoma as an adult."

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider? A.The point of maximal impulse (PMI) located at the fifth intercostal space B.Symmetrical chest movements during inhalation and expiration C.Absent visible pulsations in the area of the point of maximal impulse (PMI) D.A forceful chest movement at the midclavicular line in the forth intercostal space

D.A forceful chest movement at the midclavicular line in the forth intercostal space

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds? A.Bowel Sounds absent after 5 min B.Bowel sounds auscultated every 5 to 30 seconds C.Bowel sounds auscultated every 3 seconds D.Bowel sounds heard after 2 min

D.Bowel sounds heard after 2 min

A nurse is performing a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following conditions? A.Chest disorder B.Thyroid disorder C.Musculoskeletal disorder D.Central nervous system disorder

D.Central nervous system disorder

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider? A.Striae B.Flat, brown nevi C.Visible capillaries beneath the skin surface bilaterally D.Dimpling

D.Dimpling

A nurse is caring for a male client who reports the presence of yellow discharge from the meatus and burning with urination. Which of the following infections should the nurse suspect? A.Human papillomavirus (HPV) B.Urinary tract infection (UTI) C.Syphilis D.Gonorrhea

D.Gonorrhea

A nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can go? A.Flexion B.Rotation C.Lateral Flexion D.Hyperextension

D.Hyperextension

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. which of the following is the first step the nurse should perform during the abdominal assessment? A.Palpation B.Percussion C.Auscultation D.Inspection

D.Inspection

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take? A.Keep the bedside table at the end of the client's bed. B.Place a towel on the client's bathroom floor. C.Raise the four side rails of the client's bed. D.Keep the client's bed in the lowest position.

D.Keep the client's bed in the lowest position.

A nurse is inspecting the genitalia of an older adult female client. For which of the following findings should the nurse notify the provider? A.Sparse pubic hair B.Atrophy of the mons pubis C.Dry vaginal membranes D.Labial ulceration

D.Labial ulceration

A nurse is preparing to palpate a client's abdomen. Which of the following findings should the nurse expect? A.Involuntary rigidity B.Voluntary guarding C.Boardlike D.Nontender

D.Nontender

A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? A.Leading question B.Closed-ended question C.Direct question D.Open-ended question

D.Open-ended question

A nurse is performing a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition? A.Adverse effect of beta-blocker medication B.Recent onset of menopause C.Arterial occlusion on the right side D.Recent surgery on the right side

D.Recent surgery on the right side

A nurse is caring for a middle adult client who has stomatitis and us unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client? A.Axillary B.Temporal C.Tympanic D.Rectal

D.Rectal

A nurse is performing auscultation during a clients physical assessment. Which of the following tools should the nurse use for this part of the assessment? A.Tongue depressor B.Penlight C.Reflex hammer D.Stethoscope

D.Stethoscope

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax? A.The clients ribs slope downward at a 45 angle B.The client is making a high-pitched crowing sound that can be heard in the neck area C.The diameter of the clients chest appears barrel-like with horizontal ribs D.The client is experiencing unequal movement of the posterior chest

D.The client is experiencing unequal movement of the posterior chest

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? A.The client is sitting in a relaxed posture B.The client asks for a tissue and uses it to wipe away an occasional tear C.The client tells the nurse that visits from their friends and family make them smile D.The client reports they feel sad and lonely most of the time.

D.The client reports they feel sad and lonely most of the time.

A nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider? A.C-7 is the most prominent vertebrae B.Clicking is noted in the temporomandibular joint. C.The muscles of the neck are firm. D.There is locking of the jaw joint.

D.There is locking of the jaw joint.

A nurse is assessing the range of motion of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension? A.Turn the head from side to side and look back over the shoulders B.Bend the neck to the side and bring the ear close to the shoulder C.Lower the chin to the chest and raise it back up D.Tilt the head back and look up at the ceiling

D.Tilt the head back and look up at the ceiling

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider? A.Thin Skin B.Brown macules on the back of the hands C.Silver-white depressed scars on the abdomen D.Velvety skin

D.Velvety skin

A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries may be the newly licensed nurse is an example of correct documentation? A.I cannot sleep at night because i get short of breath B.client seems to not like certain staff members C.clients partner does not visit the client enough D.inspiratory wheeze auscultated at left lateral chest

D.inspiratory wheeze auscultated at left lateral chest

A nurse is assessing a clients skin color. Which of the following areas should the nurse check to determine the presence of pallor? A.anterior chest B.palms of the hands C.auricle of the ear D.mucous membranes

D.mucous membranes

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client (select all that apply) Dirty Clothing Unexplained physical injuries Oriented to person, place, time Able to express coherent thoughts Malnourished appearance

Dirty Clothing Unexplained physical injuries Malnourished appearance

A nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include? (select all that apply) Do not Text and Drive. Maintain spinal alignment when working at a desk. Remove loose rugs from the home. Use the back muscles when lifting objects. Wear a helmet when riding a bicycle.

Do not Text and Drive. Maintain spinal alignment when working at a desk. Remove loose rugs from the home. Wear a helmet when riding a bicycle.

A nurse is collecting information about a clients spirituality using the FICA Spiritual History Tool. Based on this tool, which of the following information should the nurse gather? (select all that apply) Does the client identify spiritual or religious beliefs that are if importance to them? What impact does the clients spiritual or religious beliefs have on their health care decision making? Are there any spiritual or religious practices that should be included when planning the client's care? What is the address of the clients identified religious or spiritual gathering place? Is there a spiritual or religious group that the client identifies as having an importance in their life?

Does the client identify spiritual or religious beliefs that are if importance to them? What impact does the clients spiritual or religious beliefs have on their health care decision making? Are there any spiritual or religious practices that should be included when planning the client's care? Is there a spiritual or religious group that the client identifies as having an importance in their life?

A nurse is preparing to inspect a male client's abdomen. Which of the following findings should the nurse identify is an unexpected finding? (select all that apply) Everted umbilicus Purple striae Rash Healed Scars Mole

Everted umbilicus Purple striae Rash

A Nurse is providing teaching to a client about screening prevention for colorectal cancer. Which of the following tests should the nurse include? (select all that apply) Fecal occult test Flec sigmoidoscopy Colonoscopy Barium enema with contract Bronchoscopy

Fecal occult test Flec sigmoidoscopy Colonoscopy Barium enema with contract

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (select all that apply) Visible pulsations observed in the carotid area on both sides of the neck. Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. Distention of the juglar vein on one side of the neck. Flattening of the juglar veins with the client sits upright The left carotid artery pulse is weak.

Full, bounding pulse noted bilaterally in the carotid arteries upon palpation. Distention of the juglar vein on one side of the neck. The left carotid artery pulse is weak.

A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (select all that apply) Gather supplies to take notes. Review the clients medical record at the conclusion of the interview. Conduct the interview in an open area such as the reception area or hallway. Select a position that is 0.6 to 0.9 (2 to 3 feet) from the client during the interview. Ensure face-to-face contact is eye level.

Gather supplies to take notes. Select a position that is 0.6 to 0.9 (2 to 3 feet) from the client during the interview. Ensure face-to-face contact is eye level.

A nurse is preparing to irrigate a clients leg wound. which of the following pieces of personal protective equipment should the nurse wear while performing this task? (select all that apply) Googles N95 mask Gown Gloves Surgical Cap

Googles Gown Gloves

A nurse is preparing to collect history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? The reason that the client is seeking health care. If the client is experiencing abuse or human trafficking. The environment in which the client resides. The clients use of substances Clients ability to perform. activities associated with daily living.

If the client is experiencing abuse or human trafficking. The environment in which the client resides. The clients use of substances. Clients ability to perform activities associated with daily living.

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (select all that apply) Instruct the client to apply warm heat for pain Instruct the client to sit with their legs uncrossed Encourage the client to avoid tobacco products Instruct the client to cleanse the area with mild soap Instruct the client to wear shoes when ambulating

Instruct the client to sit with their legs uncrossed Encourage the client to avoid tobacco products Instruct the client to cleanse the area with mild soap Instruct the client to wear shoes when ambulating

A nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend? (select all that apply) Milk Apples Mustard greens Corn Legumes

Milk Mustard greens Legumes

A nurse is assessing a client who has dark-skinned. In which of the following of the areas of the clients body should the nurse assess the client for adequate oxygenation (select all that apply) Cheeks Nail beds oral mucosa Sclerae Lips

Nail beds oral mucosa Lips

A nurse is assessing a client's wrist and hands. Which of the following findings indicates the client have have arthritis? Uneven skin tone Slight extension of the wrist Nodules on the joints A large mound below the thumb Fingers deviate toward the ulnar

Nodules on the joints Fingers deviate toward the ulnar

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation (select all that apply) Numbness and tingling of extremities Decreased chest wall expansion Lightheadedness Periods of apnea Chest pain

Numbness and tingling of extremities Lightheadedness Chest pain

A nurse is collecting information about a clients family history. The Nurse should plan to collect information about the health of which of the following of client relatives? (select all that apply) Parents Siblings Aunts and uncles Cousins Grandparents

Parents Siblings Grandparents

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (select all that apply) Penlight Tape measure Tongue depressor Needle and syringe Electrocardiogram (ECG) monitor

Penlight Tape measure Tongue depressor

A nurse is assessing a clients skin color. Which of the following findings should the nurse report to the provider? (select all that apply) Patches of increased pigmentation on the clients cheeks Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nail-beds Darkly pigmented areas across the clients sacral area Light-colored jagged lines

Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nail-beds

A nurse is gathering information about a clients personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (select all that apply) Prescription medications taken for recreational purposes. Determination of when the client last had an alcoholic drink. Frequency of consumption of over-the-counter (OTC) medications Adverse reactions to medications and environmental substances. Highest level of schooling completed.

Prescription medications taken for recreational purposes. Determination of when the client last had an alcoholic drink.

A nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (select all that apply) Pulse oximeter reading is 89% on O2 L/min via nasal cannula. Report from client says they sleep while propped on two pillows at night. Client says they quit smoking 2 years ago. Respiratory increases to 20/min when client ambulates to restroom Client states, "Being short of breath all the time is making me depressed"

Report from client says they sleep while propped on two pillows at night. Client says they quit smoking 2 years ago. Client states, "Being short of breath all the time is making me depressed"

A nurse is preparing to inspect a client's abdomen. Which of the following variations should the nurse expect to find? (select all that apply) Silver striae Rash Taut Skin Healed Scars Mole

Silver striae Healed Scars Mole

A nurse is preparing to perform an assessment on a client's abdomen. Which of the following pieces of equipment should the nurse use? (select all that apply) Stethoscope Watch Tape Measure Reflex hammer Tuning fork

Stethoscope Watch Tape Measure

A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty (select all that apply) The client occasionally sighs The client is sitting in a tripod position The clients respiratory rate is 18/min The client is using pursed lipped breathing The client appears confused

The client is sitting in a tripod position The client is using pursed lipped breathing The client appears confused

A nurse is caring for a client who is reporting pain as a 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? The client reports that the pain has been present for approximately 4 years. The client reports never feeling total relief from the pain. The client's pain can be attributed to an acute injury or illness. The client reports that the pain is recurring and does not always originate in the same location. The client describes the pain as transient.

The client reports that the pain has been present for approximately 4 years. The client reports never feeling total relief from the pain. The client reports that the pain is recurring and does not always originate in the same location.

A nurse is providing teaching to a client who asks, "What are they that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply.) Time of Day Obesity Diuretic medication Height Smoking

Time of Day Obesity Diuretic medication Smoking

A nurse is documenting information in a clients medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (select all that apply) Current Medication List Past medical History Use of assistive devices Height and weight Behavior and Mood

Use of assistive devices Height and weight Behavior and Mood