Basic Nursing Skills Quizzes
When giving a tepid sponge bath to an African American who has high fever, the nurse notices brown discoloration on the washcloth. What should the nurse's reaction be in this case?
Consider it to be normal in the client.
The nurse notes that a client's temperature has increased from 102°F to 103.6°F. Which is the most appropriate action for the nurse to take in this situation?
Consult the physician and give antipyretics to the client.
The lub-dub sound of the heart are called "S1 and S2".
True
Weight and height is generally measured and noted during the first interaction with the client.
True
A nurse is caring for a client who had a stroke. The client is lying in a supine position and is unable to reach the foot board. What should the nurse do to prevent footdrop in the client?
Use a foot splint.
An 80-year-old client has been transferred from the neurological unit to a rehabilitative unit during the client's recovery from a stroke. The client's nursing care plan includes Risk for Disuse syndrome. What intervention should be performed to address this risk?
Use a pressure-reducing device on the client's bed.
A nurse needs to change the soiled linen and body position of a client who is confined to bed and has developed bedsores. Which general principle of positioning should the nurse follow?
Raise the bed to the height of the caregiver's elbow.
Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory?
incorporating client's request for complementary treatment therapy
A nurse is showing a group of clients the correct way to move their body parts during their daily exercise regimen at a health care facility. Which effect occurs when a person adheres to proper body mechanics?
increased muscle effectiveness
A nurse greets a new client and asks the client to accompany the nurse to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:
level of consciousness.
A nurse needs to give a bath to a client with chronic back pain. Which ergonomic hazard is the nurse likely to face when caring for the client?
lifting heavy loads
During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?
macules
A nurse is caring for a client reporting lower back pain. The nurse uses the body systems approach to assess the client. What are the advantages of using this approach for data collection?
makes problems more easily identifiable, as findings tend to be clustered
The nurse is developing a menu with an Asian American client. Which food does the nurse anticipate that an Asian American client may enjoy? (Select all that apply.)
meats made with oyster and fish sauces bok choy cabbage bean sprouts rice noodles
The nurse is preparing a client who is having a routine prostate examination. Into what position will the nurse place the client?
modified standing
A nurse is caring for four clients. Which client has the highest risk of infection?
older male with an enlarged prostate
A nurse needs to examine the rectum of a constipated client for the presence of stool. The nurse should instruct the client to lie in which position?
on the left side with the right knee drawn up toward the chest
A client presents to the Emergency Department with a temperature of 100.6F and BP of 108/60 mm Hg. What intervention does the nurse anticipate providing?
oral fluids
The nurse is caring for a client who just underwent endoscopy. Which assessment finding requires immediate nursing intervention?
oxygen saturation 87%
A nurse is preparing for a skin care certification course and needs to correctly identify various lesions that may be seen on the skin. Which definitions are correct? (Select all that apply.)
papule is an elevated palpable solid mass vesicle is an elevated, round lesion filled with serum nodule is an elevated solid mass
The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?
placing the client in good alignment with joints slightly flexed
A client tells the nurse, "I am just so overwhelmed with everything that is happening to me. I have so many tests to undergo that I can't get organized, and I just wonder if it all matters." What priority nursing diagnosis does the nurse identify?
powerlessness
The nurse is preparing a client to undergo an endoscopy. What is the appropriate nursing responsibility? (Select all that apply.)
preparing the examination room obtaining equipment and supplies for the procedure ensuring the client has an identification bracelet present reporting any incorrect test preparations promptly before the procedure
The nurse is examining the anus of a client with a history of chronic constipation. What is indicative of chronic constipation?
presence of rectal fissures
The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation?
prone
A nurse who works in a large, urban hospital provides care for a diverse client population. When performing integumentary (skin) assessments, the nurse modifies assessment practices for certain clients in order to identify clinically meaningful data. This practice is most justified by the fact that clients differ according to:
race.
A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor?
reaches down to the bed to pick up a sterile drape
A nurse has assessed a client's blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mm Hg and a diastolic blood pressure of 71 mm Hg. The systolic blood pressure:
represents peak pressure in the client's arteries.
A client has an axillary temperature of 102.6 F. Which clinical manifestations would the nurse anticipate? (Select all that apply.)
respiratory rate 30/min headache red or flushed skin
The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?
risk for impaired skin integrity
The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? (Select all that apply.)
wearing a gold wedding band using at least five strokes for cleansing in each area dropping hands to side when the wash is complete
______________ are whistling or squeaking sounds heard in the lungs caused by air moving through a narrowed passage.
wheezes
A nurse is conducting a mental status assessment for a client admitted to a health care facility following a motor vehicle accident. Under which conditions would the nurse need to collect more objective assessment data?
when the client has taken an overdose of drugs
A nurse should perform hand hygiene in which circumstance?
whenever hands are visibly soiled
A nurse is assessing a client's body temperature. The nurse could obtain an accurate body temperature at the oral site for a client:
with a nasogastric tube in situ.
When teaching a group of nursing assistants about race, which statement by the nursing assistant requires intervention by the nurse?
"People with common physical features share the same culture."
The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?
"Picture yourself with good posture standing; that is how good lying posture works."
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing in bed. Keeping in mind that the client is a Latino, what is the most appropriate response by the nurse?
"Tell me what you are feeling."
A client's plan of care specifies that the client should spend the majority of time in a high Fowler position. When following this guideline, the nurse would elevate the client's head at:
60° to 90°.
Two nurses are discussing appropriate care of culturally diverse populations and a nurse has made the point that the United States is diverse but anglicized. Why is the United States considered to be anglicized?
Because United States culture evolved primarily from the early English settlers
The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?
Nurses and unit assistants use telephones with handsets.
The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?
"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin."
The nursing instructor is teaching a nursing student about the definition of diversity. Which teaching will the nursing instructor include?
"Diversity demonstrates differences among groups of people."
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness when you change position can occur when fluid volume in the body is decreased."
Which nursing intervention reflects culturally appropriate care when addressing an African American client?
"Good morning, Mr. Smith. I am your nurse, John."
The nurse has completed proper body mechanic education for a group of unlicensed assistive personnel (UAP). Which UAP statement requires the nurse to intervene?
"It is easier to twist my back when moving objects from side to side."
The nurse is teaching a client who will undergo electroencephalography (EEG) testing tomorrow. Which client statement reflects that teaching has been effective?
"My healthcare provider will tell me whether I should withhold my scheduled medications before the procedure."
An English-speaking Hispanic male has undergone a resection of the colon. The nurse observes that the client is restless and is unable to sleep. What should be the nurse's initial statement to the client?
"Tell me what you are feeling."
The client is concerned about "catching the flu." Which statement by the nurse is most appropriate?
"The best way to prevent the spread of illness is by washing your hands."
A UAP asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
"To prevent the legs from rotating outward."
A client who will undergo radionuclide imaging asks the nurse if she can be sexually active after the procedure. What is the appropriate nursing response?
"Use an effective contraception for the short period, during which radiation continues to be present in your system."
An Asian American client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had his prescribed medicines. The client believes that eating saffron will keep his blood sugar under control. What is the most appropriate response by the nurse?
"Why don't you take the medicines, too, and benefit from both?"
A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean?" How should the nurse respond?
"You are able to read at 20 feet what a person with normal vision can read at 30 feet."
A nurse is caring for an elderly client with a throat infection at the client's residence. The nurse uses a stainless steel tongue depressor to examine the client's throat. At what temperature should the nurse boil the equipment to sterilize it?
15 minutes at 212°F
A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?
3+ pitting edema
The nurse is caring for four clients. Which client presents the most susceptibility for infection?
46-year old with a foley catheter following anesthesia
A nurse who provides care on a busy medical unit works with clients who typically undergo numerous tests and examinations during their time in the hospital. Which is an example of a client who has had a laboratory test?
A client whose blood sample will be checked for the presence of bacteria
A nurse is preparing an operation theater for a surgical procedure. Which point regarding the principles of surgical asepsis should the nurse keep in mind when preparing sterilized surgical instruments?
A commercially packaged surgical item is not considered sterile if past expiration date.
A nurse is performing an assessment of a newly admitted hospital client and has documented the client as being a member of the Native American subculture. A subculture is best described as:
A unique cultural group that exists within the larger culture
A skin ___________ is an area that has been rubbed away by friction.
Abrasion
The nurse is caring for an older adult client who reports feeling dizzy when moving from sitting to standing. What teaching will the nurse provide?
Allow extra time to move from sitting to standing.
A nurse has notified an 80-year-old client's physician that the client's laboratory values indicating kidney function have fallen below the minimum reference range. The nurse should be aware of what consideration that affects the interpretation of laboratory values in elderly clients?
An older adult may have "normal" laboratory values that would be considered abnormal in a younger adult.
The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.)
Bend knees slightly to avoid straining joints. Maintain hips at an even level. Keep shoulders even and centered above hips.
The nurse is caring for a terminally ill client who is from Mexico. Which nursing intervention regarding spiritual care is appropriate?
Ask the client if a spiritual leader is desired.
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?
Ask the client to demonstrate self-blood pressure assessment.
The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing intervention?
Ask the client to open and close the fist after cuff inflation.
A nurse is working with an elderly client who possesses numerous risk factors for disuse syndrome. When assessing this client for disuse syndrome, what assessments should the nurse prioritize? (Select all that apply.)
Assess the client's bowel elimination patterns. Assess the client's cognition. Assess the client's current level of mobility. Assess the client's skin integrity.
A client with a fractured leg and arm needs to be transferred to the x-ray unit. Which nursing guideline should be followed during client transfer?
Assess the client's strength and mobility.
A Malaysian client is admitted to the health care facility with complaints of cramping pain in the abdomen and loose stools. Where should the nurse be seated when interviewing the client?
At more than one arm's distance
The nurse is teaching a client about proper use of a glucometer. Which teaching will the nurse provide?
Blood glucose levels are obtained 30 minutes before eating, and before bedtime.
Which technique should the nurse use to assess the pupillary light reflex on a client?
Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.
A nurse is caring for a client with muscle spasms due to bad sitting posture. The nurse wants to teach the client correct sitting posture. Which sitting position is good for the client?
Buttocks and upper thighs should become the base of support.
A diabetic client visits the health care facility for a blood glucose test. How should the nurse ensure that the test is accurate?
By withholding food and fluids to check the glucose level
A physician directs the nurse to get written consent from a client who has to undergo multiple laboratory and diagnostic examinations. As a rule, the written consent must confirm that the client understands the tests and will undergo them voluntarily. What other information should form a part of the client's written consent?
Capacity of the sample taken
A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?
Chest
An African American client reports to the primary health center with complaints of itching and rashes after consumption of shellfish. On examination, the nurse finds a keloid on the client's back. What is the most appropriate response by the nurse?
Consider it as normal.
A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings?
Crackles are audible in the posterior bases bilaterally and they are abnormal.
To ensure an accurate analysis, the nurse collects a specimen in an appropriate container, labels the container with correct information, attaches the proper laboratory request form, and ensures that the specimen does not decompose before it is examined. What is the last step that the nurse must take to ensure the accurate analysis of the specimen?
Deliver the specimen to the laboratory as soon as possible.
A nurse instructs a client with cognitive impairment to get into Sims position, but the client, whose word recall is diminished, is unable to understand the instruction. What should the nurse do when instructing clients with cognitive impairment?
Demonstrate the position to convey the message.
A nurse is caring for an Asian American client immediately postpartum. As the client seems exhausted after delivery, the nurse offers her warm milk to drink. The client refuses, saying that her cultural belief does not permit her to have any food before 24 hours have passed. What is the most appropriate response by the nurse?
Describe the importance of the mother's nutritional status for lactation.
A nurse is caring for a client with chronic back pain. The client attributes the pain to the client's teaching job, which involves long hours of standing in the classroom. Which position can contribute to a good standing posture and relieve the pain?
Distribute weight equally on both feet.
A client with an infection on the genitalia visits a health care facility. In order to inspect the infection, the nurse assists the client into a reclining position with knees bent. What type of position has the nurse placed the client in for inspection?
Dorsal recumbent position
After an operation, the nurse has been asked to sterilize the scalpel, scissors, and other instruments that were used during the procedure. The nurse needs to ensure that the cutting edges of these instruments are not damaged. Which is the best technique to sterilize the sharp instruments without damaging the cutting edges?
Dry Heat
A nurse is caring for a client with postural hypotension. Which nursing interventions are most appropriate to decrease the risk of falls? (Select all that apply.)
Encourage oral fluid intake. Encourage slow movement from the bed to the chair. Encourage intake of sodium-rich foods. Encourage the use of the call light for help to the bathroom.
A nurse is caring for a client with a urinary tract infection. The client is anemic and has a hemoglobin count of 8 mg/dl. Taking into consideration that the client is from a Mediterranean country, what should the nurse's most appropriate action be?
Ensure that the drug ciprofloxacin is not prescribed.
A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding?
Erythema
Which nursing intervention reflects culturally appropriate care when caring for a female Latino client?
Include the client's spouse in decision-making, if the client desires.
A nurse is caring for a postoperative Asian American client after knee arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened due to physical closeness. What would be the most appropriate nursing action?
Explain the purpose and need for assistance during ambulation.
Prolonged "tenting" of the skin when assessing skin turgor indicates edema in the client.
False
The head-to-toe approach involves a number of position changes required of the client.
False
A nurse is preparing a sterile field in order to perform a dressing change for a client. Which step should the nurse take when preparing to pour a sterile solution into the dressing tray?
First pour and discard a small amount of the solution.
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?
Fowler's
The physician needs to assess the vaginal area of a pregnant client. The nurse assists the client into a position where the client rests on her knees and chest. The client's head is supported on a small pillow, to one side. Which position has the nurse helped the client to assume?
Genupectoral position
A client with a bacterial infection has been asked to give a sample for culture. The culture will go through the gram staining process to identify the type of bacteria present. The staining process results in the bacteria changing color to red. Which type of bacteria is present?
Gram-negative bacteria
Health care professionals are required to follow certain principles to ensure that nosocomial infections do not occur in the health care facility. What contributes to infections in health care settings?
Health professionals donning artificial nails
A 4-year-old client visits the health clinic for a tetanus injection. The client is afraid of needles and is therefore restless and crying. What should the nurse do in order to coax the client to receive the injection?
Hold the client's hand and offer words of encouragement.
During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action?
Inspect the sclera and mucous membranes.
When assessing lung sounds, the nurse applies the stethoscope's chest piece to the client's upper back, but avoids placing it over the scapulae or ribs. How does this intervention help in the assessment?
It facilitates hearing sounds in the upper and lower lobes.
A nurse is caring for a client with severe burns. The client's bed has a cradle. Which feature does a cradle offer?
It forms a shell over the person's lower legs to keep bed linen off the feet.
A nurse is attending to a client with an infectious disease. After changing the linen and caring for the patient, the nurse does a hand antisepsis with an alcohol-based hand rub. Which of the following is a reason for the nurse to use an alcohol-based hand rub?
It provides the greatest reduction in microbial counts.
A nurse is caring for a client with cardiac dyspnea. The nurse assists the client into Fowler position. Which advantage does Fowler's position offer a client with dyspnea?
It relieves pressure on the diaphragm, allowing easy breathing.
A nurse needs to document client data in the computer of a health care facility. Which ergonomic recommendation should the nurse follow when working at a computer?
Keep the elbows flexed no more than 100° to 110°.
The nurse is caring for an older adult client. Which gerontologic consideration regarding laboratory values does the nurse anticipate?
Laboratory values change minimally or not at all.
An Anglo American client reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind?
Maintain eye contact while talking.
An Arab client has been admitted to the health care facility with varicose veins. What should the nurse avoid while conducting the interview of the client?
Maintaining eye contact
The nurse is caring for a client who is undergoing an internal diagnostic gynecologic test. The client expresses to the nurse, "I am afraid that this will hurt." What is the appropriate nursing response?
Offer to stay with the client during the test.
A 22-year-old woman who recently emigrated from Laos has been admitted to the hospital with an ovarian cyst. Both the client and her husband speak Lao exclusively and this has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take in order to communicate with the client?
Organize professional interpretation, either in person or by telephone.
A nurse is assessing a client and observes jaundice on the skin and hard palate on the sclera bilaterally. What is the appropriate action of the nurse?
Palpate the liver for enlargement.
When sterilizing the endoscope used for a client, what should the nurse use?
Peracetic acid
The method of _______________ involves striking or tapping part of the client's body with the fingertips to produce vibratory sounds.
Percussion
An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?
Perform surgical hand scrub using detergent.
A nurse is assisting a physician in examining a client. During the procedure, the nurse hands the physician one instrument at a time. What other method can the nurse use to assist the physician promptly and properly?
Place the instruments near the physician's dominant hand.
A nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit?
Pour and discard a small amount of the solution.
A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature?
Proteins
A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs?
Provide warm fluids.
Before performing a blood glucose test using a glucometer, the nurse asks the client if he has ever had his blood glucose level measured using a glucometer before. Which statement is a possible reason for the nurse to ask this question?
Provides basis for teaching
A client visits the health clinic with a report of slight chest discomfort. Which test should the client undergo in order to determine the cause of the discomfort?
Radiography
The nurse is performing client education with a 58-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control their blood pressure?
Reduce sodium intake.
A nurse is observing a client who is lying on an oscillating bed. Which pressure-relieving action does an oscillating bed offer?
Relieve skin pressure.
A nurse is caring for a client with Lyme disease. What causes Lyme disease?
Rickettesiae
A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these?
Rubs
A nurse is assessing the hearing acuity level of a client using audiometric hearing tests. The decibel range at which the client can hear is recorded as 78 dB. What is the hearing level of the client?
Severely impaired
The nurse is preparing a female client of childbearing age for a radiographic examination. What is the priority nursing intervention?
Shield the client with a lead apron.
A nurse is caring for an arthritic client who needs administration of an enema. Which position should the nurse ask the client to maintain to administer the enema solution?
Sims' position
A labor and delivery nurse will be participating in a client's emergency caesarean section and intends to apply the principles of surgical asepsis appropriately. Surgical asepsis is most clearly characterized by:
Steps are taken to render an item completely free of microorganisms.
When measuring a client's pulse rate, the nurse records 125 bpm. How will the nurse document the information in the medical records?
Tachycardia
A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? (Select all that apply.)
Temperature is 101.4° F (38.6 C.). Heart rate is 130 beats per minute. Oxygen saturation is 90%. Pain is 8 on scale of 1-10
A 30-year-old client is scheduled for a blood glucose test. The nurse helps the client to change into an examination gown, applies an identification bracelet, and takes the client's vital signs. What else should the nurse ensure before the client undergoes the test?
That the client provides written consent before the test
An Asian American client is scheduled for discharge after being diagnosed with type 1 diabetes mellitus. Before leaving the health care facility, the nurse demonstrates the technique of self-administration of insulin and explains the importance of the client's prescribed insulin regimen in controlling blood sugar levels. What may the nurse conclude if the client continues to stare blankly?
The client disapproves of the insulin treatment.
A physician directs the nurse to get written consent from a client who has to undergo multiple laboratory and diagnostic examinations. As a rule, the written consent must confirm that the client understands the tests and will undergo them voluntarily. What else is necessary to make the client's written consent valid?
The client must be able to make rational decisions.
A pregnant client visits a health care facility for her scheduled checkup before her delivery date. The physician needs to check the client's reproductive organs for any kind of irritation or discomfort. The physician asks the nurse to help the client into the lithotomy position. Which statement describes the lithotomy position?
The client should be in a reclining position with the feet in stirrups.
A client is admitted to a health care facility with a report of nausea, headache, and abdominal pain. The physician suggests that the client undergo a series of tests to determine the exact cause of the client's condition. After the physician leaves, the client appears restless and anxious. What should the nurse do in this case?
The nurse must repeat the need for the test to the client.
A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation following myocardial infarction. Keeping in mind that the client is a Latino, how should the nurse conduct the interview?
The nurse should avoid using medical terminology.
The Rinne test is an assessment technique for comparing air versus bone conduction of sound.
True
A physician has ordered an ECG for a client with a report of chest pain. Apart from obtaining the equipment needed to conduct the test, what important task should the nurse perform before the test is administered?
The nurse should check the instruments that require electric power.
A client has been admitted to a health care facility with high fever and severe body pain. When assessing the client's temperature every 30 minutes, the nurse notes that the client's condition has not been improving. The nurse has been directed by the physician to prepare the client for a blood test to check for viral infection. What is the first step the nurse should take before collecting the blood sample for the test?
The nurse should explain to the client the purpose and need for the test.
A client who does not speak English has been admitted to the health care facility reporting chest pain. Since the assigned nurse does not know the client's language, what would be the most appropriate solution in this case?
The nurse should request the help of a professional interpreter.
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
Thready pulse
A nurse is caring for a client with impaired mobility. What is the purpose of the trochanter roll?
To prevent the legs from turning outward
A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape with which to cover the client. What is the primary purpose of providing a drape during the assessment process?
To provide the client with modesty during the assessment
A client with TB has been discharged from the health care facility. What care should be taken with regard to cleaning the bed linens used by the client during his stay at the facility?
Wash them with boiling water.
A nurse is informing a nursing student about the Centers for Disease Control and Prevention (CDC) guidelines for hand asepsis. Which guideline is in compliance with the CDC guidelines for hand washing?
Washing when hands are visibly soiled
A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning a client's open wounds to protect the nurse from infection?
Wear a clean pair of latex or latex-free gloves.
When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take in order to prevent becoming infected?
Wear a mask when caring for the client.
A nurse is observing the housekeeping staff when they are cleaning a health care facility. Which principle should the housekeeping staff follow for medical asepsis?
Wet-mop floors to avoid distributing microorganisms.
A nurse has been asked to record a client's body temperature every hour using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer?
Wipe with isopropyl alcohol.
The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis?
a pronounced lateral curvature of the spine
When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?
ability to identify fine touch
During the physical assessment of a 12-year-old child who sustained injuries in a bicycle fall, the nurse observes an area near the elbow that has been rubbed away by friction. How should the nurse document this finding?
abrasion
Bowel sounds are described as _________________ if no sound is heard for two to five minutes.
absent
A nurse needs to measure the blood pressure of a client with an electronic manometer. Which advantage does an electronic manometer provide over an aneroid manometer or mercury manometer?
accurate for practitioners with hearing loss
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?
applying a blanket
------------------- is a sophisticated test of range of hearing that measures hearing acuity at various sound frequencies.
audiometry
A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound?
shorter on inspiration than expiration, with a pause between them
Which action made by the nurse provides the best assessment data for presence of jaundice?
checking the hard palate
A nurse is caring for four adult clients. Which client would the nurse assess first?
client with a respiratory rate 32/min
A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe?
coordinated movement of both eyes
A nurse is assessing a client's vital signs at a health care facility. The nurse observes that the client is sweating profusely. What body area causes a client to sweat?
hypothalamus
A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test?
determines the equality or disparity of bone-conducted sound
A nurse has responded to a client's call light and found the client gasping and saying, "I can't get my breath." The nurse applied supplementary oxygen and repositioned the client, which led to the relief of the client's symptoms. When documenting this event, the nurse should note that the client was experiencing:
dyspnea.
A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites corresponds most closely to the client's core body temperature?
ear
A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must:
ensure that the roller sheet is kept dry and wrinkle-free.
A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?
exit route
A wheelchair-bound client reports the "hammock effect" each time the client sits in the wheelchair. Which device should the nurse place in the wheelchair to prevent the hammock effect?
gel and foam cushions
A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature?
great surface area relative to mass and very high metabolic rate
A student nurse is preforming hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?
has manicured nails that are 1-inch long
A nurse is using a mechanical lift to assist an obese client with limited mobility. Which client will benefit the most from a mechanical lift?
heavy
A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening?
height and weight
The nurse directs the UAP to assist a client with eating. Into which position will the nurse delegate the UAP to place the client?
high Fowler's
A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive:
if sounds occur after a long interval.
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
immediately
A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope?
slightly below the left nipple
A nurse is assessing the home environment of an elderly client with limited mobility. What recommendation by the nurse would most likely increase the client's confidence in ambulation in the home environment?
strategically placed handrails
A nurse is caring for a client with severe back pain. The client has been lying flat on his back in bed for a long time. Which body position has the highest potential for causing footdrop in a bedridden client?
supine
A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?
to check the skin temperature and moisture
A public health nurse has been asked to participate in an initiative that is aimed at promoting the use of ergonomics. What is the most likely goal of this initiative?
to promote comfort and health in workplace settings
A nurse needs to transfer a client who has polio but has strong arms and upper body muscles to the x-ray unit. Which transfer devices will be most suitable for the client?
transfer board
A nurse is caring for a client who is recovering from acute back pain. Which device will allow the bedridden client to maintain as much independence as possible?
trapeze
A nurse is caring for a client with low body temperature. Which of these thermometers should be the nurse's first choice to measure the client's body temperature?
tympanic
