Basic Physical Assessment - ML8

A client asks the nurse why the prostate-specific antigen (PSA) level is determined before the digital rectal examination. What should the nurse tell the client? "A prostate examination can possibly decrease the PSA." "If the PSA is normal, the client will not have to undergo the rectal examination." "A prostate examination can possibly increase the PSA." "It is easier for the client."

"A prostate examination can possibly increase the PSA." Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are no longer recommended as screening tools for prostate cancer. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age group.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma? "A burning sensation under the stoma faceplate is normal." "The stoma should remain swollen distal to the abdomen." "The stoma should appear dark and have a bluish hue." "At first, the stoma may bleed slightly when touched."

"At first, the stoma may bleed slightly when touched." The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

To evaluate a client's cerebellar function, a nurse should ask "Do you have any trouble swallowing food or fluids?" "Do you have any difficulty speaking?" "Have you noticed any changes in your muscle strength?" "Do you have any problems with balance?"

"Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help the nurse evaluate the client's motor system.

The nurse is performing a complete neurological assessment on an older adult client. Which question by the nurse would best assess cerebral function? "Have you noticed a change in your muscle strength?" "Have you had any problems with walking or coordination?" "Have you had any problems with blurry vision?" "Have you noticed a change in your memory?"

"Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help assess cerebellar function. Questions about eyesight help evaluate the cranial nerves associated with vision.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? "I should drink more water when feeling thirsty or becoming irritable." "Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded." "Dehydration is only a problem in the summer months when it's hot outside." "If my skin becomes dry and itchy I can apply extra lotion."

"I should drink more water when feeling thirsty or becoming irritable." Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse? "Rheumatoid arthritis does not have a genetic basis, so there is nothing to be concerned about." "There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." "Have your child take aspirin for a few days to see if the stiffness is relieved." "It is normal to have aches and pains, so your concern is probably unwarranted."

"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." Some research has indicated that a genetic link may be present. Suggesting that the child take aspirin is incorrect because that is offering medical advice and is out of scope of practice of a nurse. Reassuring the client is providing false reassurance.

Which is the highest priority action by the nurse before starting this skill? Flush tube with 100 cc of water. Assess stomach residual. Assess bowel sounds. Place client in the supine position.

Assess stomach residual. Assess stomach residual.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring. Check vital signs and level of consciousness; then place the client in a quiet area with a family member. Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Monitor the level of agitation and, when the client calms down, refer to the community addiction team.

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

Which sound should the nurse expect to hear when percussing a distended bladder? Dullness. Flatness. Hyperresonance. Tympany.

Dullness. A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drum-like sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? Level of consciousness, pain level, and wound dressing Emotional status, response to anesthesia, and social support systems Metabolic rate, orientation, and presence of reflexes Skin color, warmth of extremities, and mental status assessment

Level of consciousness, pain level, and wound dressing Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Obtain vital signs. Insert an NG tube and connect to suction. Assess bowel sounds and abdominal tenderness. Document history of the symptoms.

Obtain vital signs. The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement.

Why should the nurse avoid palpating both carotid arteries at one time? Palpating both arteries at one time may cause transient hypertension. The nurse can't assess the pulse accurately unless the arteries are palpated one at a time. Palpating both arteries at one time may cause severe tachycardia. Palpating both arteries at one time may cause severe bradycardia.

Palpating both arteries at one time may cause severe bradycardia. The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

Which sentence correctly describes the prone position? Arms are elevated at shoulder level. The body is facedown. The body is facing backward. The body is supine.

The body is facedown. In the prone position, the body is facedown with the head to the side.

Which finding will the nurse assess in a client diagnosed with peritonitis? absence of bowel sounds abdominal wall rigidity positive Cullen's sign Battle's sign

abdominal wall rigidity Abdominal wall rigidity is a common manifestation of peritonitis. Bowel sounds may or may not be present in peritonitis. A positive Cullen's sign is a manifestation of acute pancreatitis, and Battle's sign is a manifestation of skull fractures.

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition? allergies fifth disease sinusitis ringworm

allergies In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease.

The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170 cm) female client who is 21 years of age? brittle nails weight of 128 lb (58.1 kg) poor posture dull expression

brittle nails Brittle nails indicate poor nutrition. Poor posture indicates that the client does not stand up straight and use her muscles to support herself. A dull expression reflects the client's affect and emotional status. The client's weight of 128 lb (58.1 kg) is within normal range.

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client? broth, gelatin cubes, and tea bananas, rice, applesauce, and toast milk, custard, and vanilla ice cream a bland diet tray

broth, gelatin cubes, and tea To begin the patient's transition to eating a regular diet, the nurse will first choose a clear-liquid diet. This includes transparent liquids, such as apple juice, ginger ale, and chicken broth. When clear liquids are tolerated, the client can then transition to a full-liquid diet consisting of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. Although milk, custard, and vanilla ice cream may be included in a bland diet, it may also include semi-solid and solid foods that are not spicy. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, and toast.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? carotid radial apical brachial

carotid During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) are no longer palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include decreased posterior thoracic curve. decreased peripheral resistance. delayed gastric emptying. increased coronary artery blood flow.

delayed gastric emptying. Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription? antihypertensive medication increased oxygen liter flow rate additional fluid intake diuretic medication

diuretic medication The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

The nurse states on shift handoff that the client has an elevated uric acid level of 8.2 mg/dl (487.8 mmol/L). Which inflammatory process would the nurse assess for during client assessment? gout rheumatoid arthritis lupus erythematosus Paget's disease of the bone

gout Normal gout levels are 4 to 8 mg/dl (237.9 to 475.9 mmol/L). Uric acid levels that exceed 6 mg/dl (356.9 mmol/L) provide an elevated risk for gout. Gout is a medical condition with symptoms of acute inflammatory arthritis that is caused by high levels of uric acid in the blood. The client can develop uric acid crystal deposits in the joint. The nurse would assess joint areas for pain, redness, and swelling. Rheumatoid arthritis is a chronic disease of joint inflammation and pain. Lupus erythematosus is a chronic tissue disorder of the connective tissue and is known to have an elevated antinuclear antibody level. Paget's disease of the bone also known as Paget's disease is a condition involving cellular remodeling with deformities in one or more bones. It is diagnosed by an x-ray.

Which component of a client's medical record is the major source of subjective data about the client's health status? radiologic findings physical findings laboratory test results health history

health history Only the health history provides subjective data. Physical findings, laboratory test results, and radiologic findings are examples of objective data.

A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client? dehydration causes the skin to appear edematous and spongy overhydration causes the skin to tent normal skin turgor is moist and boggy inelastic skin turgor is a normal part of aging

inelastic skin turgor is a normal part of aging Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first? acetaminophen orally as needed intravenous fluid hydration small-volume nebulizer breathing treatments regular diet

intravenous fluid hydration Both the history and physical assessment indicate a client who is dehydrated. IV fluids would assist with rehydration and liquifying secretions. Although it will be important to treat the pneumonia aggressively, hydration is the priority.

When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis? inner aspects of the wrists oral mucous membranes retinas nail beds

oral mucous membranes In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment for determining cyanosis in any client.

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client? auscultation percussion inspection palpation

palpation The nurse caring for the client with right lower quadrant abdominal pain would perform a complete abdominal assessment including inspection, auscultation, percussion, and palpation, but palpation is the most important. The nurse must assess for tenderness with palpation, which is associated with inflammation of the peritoneal cavity and may be caused by appendicitis. The report of tenderness with palpation is often the defining factor when planning care for the client with right lower quadrant pain.

The nurse is reviewing the electronic health record of a newborn with pathologic jaundice receiving phototherapy. What factors put this newborn at risk for hyperbilirubinemia? Select all that apply. Native American/First Nations ethnicity small for gestational age (SGA) prematurity ABO incompatibility breastfeeding

prematurity Native American/First Nations ethnicity ABO incompatibility Breastfeeding and small for gestational age are not risk factors for pathologic jaundice. Prematurity, Native American/First Nations ethnicity, and ABO incompatibility are risk factors for pathologic jaundice.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are rapid, deep breaths with abrupt pauses between each breath. rapid, deep breaths and irregular breathing without pauses. shallow breaths with an increased respiratory rate. progressively deeper breaths followed by shallower breaths with apneic periods.

progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding? pulse amplitude +1 bilateral lower extremities poor quality of peripheral pulses pulse amplitude +2 bilaterally pulses weak

pulse amplitude +1 bilateral lower extremities The nurse should document the amplitude as weak or bounding, or according to the amplitude scale of 0 - +4. Zero would indicate no pulse, +1 weak, +2 normal +3 full, +4 bounding. Location should be specifically documented. Pulse amplitude of +1 in bilateral lower extremities is more specific than the term weak or poor quality without description of location of weak or poor pulses. Pulse amplitude of +2 indicates normal findings.

What are important nursing responsibilities when a referral to other health team members has been made for a client? sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living recommending that each health team member independently completes an assessment and then consult with each other recommending that each member read the history and nurse's notes to understand the client's progress ensuring that the physician reports the level of functioning of the client

sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? stress fractures fat embolus thrombophlebitis air embolus

thrombophlebitis Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about? moderate amount of serous drainage on the surgical dressing temperature of 37.6° C (99.7° F) blood pressure of 100/70 mm Hg urinary output of 20 mL/hr over 2 hours

urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care provider. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider? nails are thickened, brittle, and yellow increased sensitivity to glare lower peripheral pulses +1 bilaterally urine output of 600mL/24 hours

urine output of 600mL/24 hours Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.

The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output? weighing the diaper before and after micturition monitoring the amount of time for breast feeding measuring the formula before the child ingests it weighing the child before and after feeds

weighing the diaper before and after micturition Weighing the diaper before applying it to the newborn, infant, or toddler, and then weighing it after micturition will help evaluate the urine output. The difference between the wet diaper and the dry one will give the amount of urine (1 g = 1 mL, so amounts may be recorded in milliliters). Weighing the child or measuring the formula will not give an indication of evaluating the urine output in this situation.

A client has had hoarseness for more than 2 weeks. What should the nurse do? Instruct the client to gargle with salt water at home. Refer the client to a health care provider for a prescription for an antibiotic. Assess the client for dysphagia. Instruct the client to take a throat analgesic.

Assess the client for dysphagia. Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? Assess the client's level of pain, and administer prescribed analgesics. Prepare the client for pulmonary artery catheterization. Ensure that the client's family is kept informed of the client status. Assess the client's level of anxiety, and provide emotional support.

Assess the client's level of pain, and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and their family should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment? speaking loudly and slowly addressing the client by first name shortening it due to possible client fatigue allowing extra time for the assessment

allowing extra time for the assessment When assessing an older adult client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? a passage of flatus pre- and post-feeding inability of the client to receive a rapid flow of the feeding formula in the client's mouth during the feeding, and increased cough intermittent epigastric tenderness

formula in the client's mouth during the feeding, and increased cough Formula in the mouth and cough are indicators of aspiration. Passage of flatus reflects intestinal motility, which does not pose a potential problem. A passage of flatus is not reflected in tolerating a feeding, it is an indication of bowel function. A rapid flow should not be administered by a nurse, and gastric tenderness does not indicate tolerance of tube feed.

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client? "Do you need special equipment to walk?" "Do you wear glasses?" "Do you have difficulty swallowing?" "Do you smoke?"

"Do you wear glasses?" The nurse would ask whether the client wears glasses to evaluate the client's preoperative cognitive-perceptual pattern. Asking about the client's swallowing pattern would evaluate the client's nutritional-metabolic pattern. Asking about the client's need for special equipment to walk would evaluate the client's activity-exercise pattern. Asking about the client's history of smoking would evaluate the client's health perception-health management pattern.

An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client? Inspect the urethral meatus for urine discharge. Percuss dullness in the lower left quadrant. Determine rebound tenderness below the symphysis. Palpate for a rounded swelling above the pubis.

Palpate for a rounded swelling above the pubis. The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate.

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply. siblings with allergies allergies to items other than medications, such as foods and animals favorite foods allergies to any medications reaction to the allergen severity of the allergy

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy When assessing the past health history of a child, it is important to determine if the child has any medication and/or non-medication allergies, the reaction the child has to the allergen, as well as the severity of the allergy. Favorite foods and sibling history of allergies are not important to assess here.

The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should: listen for 2 minutes in each area of the abdomen. expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. ask the client to drink a glass of warm water prior to auscultation. use the bell of the stethoscope.

expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 5 minutes, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds.

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? assessing at the beginning and the end of the examination in the supine, sitting, and standing positions taking blood pressure on the left arm and again in 5 minutes on the right arm ambulating the client around the room and then assessing blood pressure

in the supine, sitting, and standing positions By assessing the client's blood pressure in these positions, the nurse can calculate the client's postural pressure, understanding the increase or decrease in blood pressure from a lying to sitting or sitting to standing position. Ambulating the client and taking in the left and then again in the right arm are not accurate assessment tools. Assessing at the beginning and end of the exam is incorrect because this measures a deficit and is not a tool for hypotension.

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used.

Inspection Auscultation Percussion Palpation

The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note? B A C

C Epispadias is characterized by the urethral opening at the top (dorsal) aspect of the penis. Though the child will be able to urinate, surgical repair will be completed. Option A is the normal opening of the urethra at the tip of the penis. Option B documents hypospadias with the urethral opening at the underside (ventral) aspect of the penis.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? Request an order to insert a Foley catheter. Force fluids to encourage voiding. Initiate hourly intake and output measurement. Palpate for the bladder above the symphysis pubis.

Palpate for the bladder above the symphysis pubis. Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention? Perform a bladder scan, and obtain an order for urinary catheterization. Reassure the client that this is a normal voiding pattern. Offer the client a warm compress, and observe for worsening discomfort. Administer the prescribed analgesic, and repeat the client's vital signs in 20 minutes.

Perform a bladder scan, and obtain an order for urinary catheterization. The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.

Which client should the nurse assess first? a client with chronic hypertension whose blood pressure today is 182/98 mm Hg a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week a client being treated for chronic stable angina who reports a recent increase in chest pain frequency a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

Which factors are major components of a client's general background history? urine output and allergies bowel habits and allergies allergies and socioeconomic status gastric reflex and the client's age

allergies and socioeconomic status General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

The nurse is caring for a 1-month-old infant who fell from the changing table during a diaper change. Which signs and symptoms of increased intracranial pressure (ICP) is the nurse likely to assess in a 1-month-old infant? Select all that apply. headache high-pitched cry decreased blood pressure irritability increased pulse bulging fontanels

bulging fontanels high-pitched cry irritability Signs and symptoms of increased ICP in a 1-month-old include full, tense, bulging fontanels; a high-pitched cry; and irritability. With increased ICP, blood pressure rises while heart rate falls. The infant may have a headache but the nurse cannot assess this finding in an infant.

The nurse is assessing a client's testes. Which finding indicate the testes are normal? lumpy egg-shaped spongy soft

egg-shaped Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the health care provider (HCP).

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? alteration in level of consciousness alteration in urinary elimination ineffective breathing pattern altered cardiac functioning

ineffective breathing pattern The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? referring a client who reports joint pain to a healthcare provider specialist obtaining a rubella titer on a woman who is planning to start a family teaching a client who has asthma how to use a rescue inhaler administering digoxin to a client who has heart failure

obtaining a rubella titer on a woman who is planning to start a family Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? pulsus regularis pulse deficit pulse pressure pulse rhythm

pulse deficit The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the difference between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action? reddened tympanic membrane without discomfort light reflecting off the ear drum surface fine hairs in the auditory canal with dark brown wax visualization of the ossicles through the tympanic membrane

reddened tympanic membrane without discomfort To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Normal findings should include visualization of the ossicles through the tympanic membrane, fine hairs in the auditory canal with wax, and reflection of light off the light-gray or pearly white shiny ear drum. A reddened ear drum would indicate an infection with or without pain.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first? Call the respiratory therapist. Call the health care provider (HCP). Call the rapid response team (RRT)/medical emergency team. Call the PACU.

Call the rapid response team (RRT)/medical emergency team. The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate? cardiac monitoring, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin split product values EEG (electroencephalogram), alkaline phosphatase and aspartate aminotransferase levels, and basic serum metabolic panel

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Diagnostic testing is one source of information leading to a medical diagnosis. It is correct to anticipate cardiac and gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure? Inflate the cuff at least another 30 mm Hg after the nurse can't palpate the radial pulse. Inflate the cuff to at least 200 mm Hg. Take blood pressure readings in both of the client's arms. Have the client lie down while taking the client's blood pressure.

Inflate the cuff at least another 30 mm Hg after the nurse can't palpate the radial pulse. The nurse should wrap an appropriate-size cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until unable to palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg. Having the client lie down, inflating the cuff to at least 200 mg, and taking blood pressure readings in both of the client's arms aren't appropriate measures.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? Inquire about the health of siblings at home. Institute droplet precautions. Ask the parent about medication allergies. Obtain the child's vital signs.

Institute droplet precautions. The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress? The client's pulse and respiratory rate returned to baseline 1 hour after activity. The client reported feeling dizzy and weak and perspired profusely. The client's head was down, gaze was cast down, and toes were pointed outward. The client's pulse and respiratory rates increased moderately during ambulation.

The client's pulse and respiratory rates increased moderately during ambulation. Pulse and respiratory rates normally increase during, and for a short time after, ambulation, especially if it is the first ambulation after 3 days of bed rest. Vital signs should return to baseline within 5-10 minutes after activity. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury? The client will return to optimal level of functioning. The client will use the adaptive devices to assist with feeding. The client's vital signs will stabilize, returning to normal range. The client's skin will remain clean, dry, and intact.

The client's vital signs will stabilize, returning to normal range. During the acute phase of a neurological injury, the goal of nursing management is to stabilize the client to prevent further neurological damage. A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to normal range. Using adaptive devices would occur in the recovery or chronic phase of a neurological deficit. The client's skin and returning to optimal level of functioning is a goal for later in the recovery process.

The nurse is assessing a client's deep tendon reflexes. Which graphic shows assessing the biceps reflex?

To test the biceps reflex, the client's elbow is flexed at a 45° angle. The nurse's thumb or index finger is placed over the biceps tendon and the nurse strikes the digit with the pointed end of the reflex hammer, watching and feeling for the contraction of the biceps muscle and flexion of the forearm. Option A shows assessment of the patellar reflex. Option B shows assessment of the brachioradialis reflex. Option D shows assessment of the triceps reflex.

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first? Call the health care provider (HCP). Use a Doppler ultrasound device. Auscultate the pulses with a stethoscope. Inspect the lower left extremity.

Use a Doppler ultrasound device. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse is not palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the HCP may be necessary if there is a change in the client's condition.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do? Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Request that the laboratory send the results by email to transfer to the client's medical record. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the medical record. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery.

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via email is unacceptable due to potential security and privacy issues.

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's prognosis? as soon as the client is warmed when the client's blood pressure has stabilized as soon as cardiopulmonary resuscitation is successfully initiated 3 days after the incident

as soon as the client is warmed The neural or hemodynamic status of the client cannot be determined until the client is warmed. The nurse would not have to wait 3 days to do so. Stable blood pressure is important, but the determining factor is the client's core body temperature.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control? The client exhibits signs of adequate GI perfusion with normal bowel sounds. The client verbalizes a manageable level of discomfort. The client maintains skin integrity. The client expresses positive feelings about self-image.

The client exhibits signs of adequate GI perfusion with normal bowel sounds. Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate: metabolic alkalosis. respiratory acidosis. metabolic acidosis. respiratory alkalosis.

respiratory acidosis. Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding? "Dehydration is only a problem in the summer months when it's hot outside." "I should drink more water when feeling thirsty or becoming irritable." "If my skin becomes dry and itchy I can apply extra lotion." "Vitamin hydration drinks would be good when I feel my heart pounding and become lightheaded."

"I should drink more water when feeling thirsty or becoming irritable." Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action? Assess the client's temperature. Notify the health care provider. Clean with antiseptic material and re-dress the site. Evaluate the client's white blood cell count.

Assess the client's temperature. Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane? Grasp the auricle with the nondominant hand, and pull up and back. Grasp the auricle with the nondominant hand, and pull down and back. Grasp the auricle with the nondominant hand, and pull straight up. Grasp the auricle with the nondominant hand, and pull down and forward.

Grasp the auricle with the nondominant hand, and pull down and back. The ear canal slants up in a younger child and down in an older child or adult. To best visualize the tympanic membrane in an infant, the nurse would grasp the auricle with the nondominant hand and pull down and back to a 6:00 to 9:00 position to straighten the ear canal. The nurse would pull up and back toward a 10:00 position to best visualize the tympanic membrane in an adult or older child. Pulling straight up or down and forward will not be effective in straightening the ear canal as needed for visualization of the tympanic membrane.

At 8:00 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10:00 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next? Immediately notify the health care provider of these findings. Check to see that the client had a chest X-ray the previous day as ordered. Sign the preoperative checklist for this client. Check the client's serum electrolyte levels and complete blood count (CBC).

Immediately notify the health care provider of these findings. The nurse would notify the health care provider immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse would then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse would sign the preoperative checklist after notifying the health care provider of the client's condition and learning whether the provider will proceed with the scheduled surgery.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected? There is redness and swelling at the aspiration site. There is no bleeding at the aspiration site. The client requests a strong analgesic for pain. The client maintains bed rest.

There is no bleeding at the aspiration site. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? Call the surgeon to come to the client's room immediately. Have all visitors and family leave the room. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. Press the emergency alarm to call the resuscitation team.

Cover the abdominal organs with sterile dressings moistened with sterile normal saline. When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli? spontaneous verbal tactile painful

tactile This client is responsive to tactile stimulation, because the client responded when the nurse touches the skin. Spontaneous response would refer to the client who was awake, alert, and required no intervention on the nurse's part to elicit a response. If the client had responded to the nurse saying the client's name, this would be a response to verbal stimuli. The client does not require painful stimuli, such as nail bed pressure, trapezius squeeze, or sternal rub, to get a response.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes. Place the client on NPO status, and notify the health care provider immediately.

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Gathering information regarding possible causes of nausea helps identify changes and factors that relate to the changes. Modifying the schedule helps. Although administering an antiemetic may be beneficial, movement and activity immediately afterward will not be helpful, because the medication has not yet taken effect. Diet is not the issue, so the diet-related choice is not correct. Nausea and weakness are not an emergency and do not require immediate notification of the health care provider.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan? Follow the formal written plan of action for coordinating the response of the hospital staff. Transport medical supplies to where casualties are being evaluated. Contact and inform all registered nurses about the disaster to elicit their help in assisting with the casualties. Volunteer to report to whichever unit needs the most assistance.

Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed? Pulse oximetry changes from 85% to 89%. Client is coughing out yellow sputum. Respiratory rate drops from 24 breaths/minute to 16 breaths/minute. Coarse breath sounds in anterior chest diminish.

Respiratory rate drops from 24 breaths/minute to 16 breaths/minute. Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, increased pulse rate, and bubbling breath sounds indicate respiratory secretion accumulation.

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client? Check the cervical mucus to see if it is thick and sparse. Take her temperature at the same time every morning before getting out of bed. Document ovulation when her temperature decreases at least 1°F (0.56°C). Avoid coitus for 10 days after a slight rise in temperature.

Take her temperature at the same time every morning before getting out of bed. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F (0.28° C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.

After administering prescribed medications to clients, which client requires immediate intervention? a client with a nitroglycerine patch who has a headache a client taking digoxin who has a morning potassium level of 3.0 mEq/L a client taking captopril who has a nonproductive cough a client taking atenolol who has a heart rate of 58

a client taking digoxin who has a morning potassium level of 3.0 mEq/L The client's low potassium level increases the risk for digoxin toxicity and potential dysrhythmias. Digoxin inhibits the action of the sodium-potassium pump that moves sodium and potassium across the cell membrane and slows the electrical impulses through the atrioventricular node. This leads to a rapid reduction of the remainder of potassium ions available for the "pump" action, which can cause a buildup of toxic serum levels of digoxin. Digoxin toxicity can cause many types of cardiac dysrhythmias due to the increased intracellular calcium release and decreased AV conduction time slowing the heart rate. The nurse should notify the healthcare provider about the potassium level to prevent toxicity from occurring. The other clients are experiencing expected effects of the prescribed medication.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? applying an external fetal monitor and performing a sterile vaginal examination obtaining fundal height and performing a sterile vaginal examination applying an external fetal monitor and completing a physical assessment obtaining a fundal height assessment on the client

applying an external fetal monitor and completing a physical assessment Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? signs of kidney suppression with enlargement of the kidneys, reduced urine flow, and concentrated urine signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes signs of abdominal distension, auscultation of reduced bowel sounds, and tympany upon percussion signs of metabolic alkalosis with disorientation because of loss of intestinal fluids

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss. A focused assessment would usually indicate increased bowel sounds associated with the cramping. Kidney suppression would not be associated with diarrhea lasting 2 days; it might present with severe dehydration and hypovolemic shock. There is a loss of bicarbonate through the diarrhea, which would result in metabolic acidosis, not alkalosis.

The emergency department (ED) nurse should assess which client first? a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain a 72-year-old who fell from the porch and has a painful probable fracture of the right arm a 12-year-old who has a bleeding laceration on the knee possibly requiring stitches a 3-day-old who the parents identify as having yellow discoloration on the chest and abdomen

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain When the nurse is presented a choice between who to see first, safety and seriousness of the condition are considerations. The individual from the motorcycle accident is stating pain that could indicate internal injuries, a serious complication. This individual would be assessed by the nurse first. Through delegation and prioritization of the remaining clients, the others will have their needs met by the registered nurse and members of the health care team. The nurse identifies physiological jaundice in the 3-day old neonate. Diagnostic lab work will be completed and parental teaching on increasing feedings. A simple dressing on the bleeding laceration could be placed by a licensed practical/vocational nurse or nursing assistant until seen by the healthcare provider. The fractured arm will be examined and x-rayed confirming the fracture.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? a 13-year-old with a fever of 104° F (40° C), chills, and a cough with thick yellow secretions a 4-year-old with a fever of 101° F (38.3° C), a hoarse cough, inspiratory stridor, and restlessness a 3-year-old with a fever of 100° F (37.8° C), a barky cough, and mild intercostal retractions a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

The nurse has received the change-of-shift report on the clients. Who should the nurse assess first? a client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due a client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am (1000) for an ablation a client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70

a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound? closing of the mitral and tricuspid valves opening of the mitral and tricuspid valves opening of the aortic and pulmonic valves closing of the aortic and pulmonic valves

closing of the aortic and pulmonic valves The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? increased scarring decreased melanin and melanocytes increased immunocompetence decreased healing

decreased healing Normal aging consists of decreased proliferative capacity of the skin. Decreased collagen synthesis slows capillary growth, impairs phagocytosis among older clients, and results in slow healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes give color to the skin and hair but are increased with aging. There is a decrease in the immunocompetence of the aging client.

The nurse has just received report on four clients. Which client should be seen first? a client who had a cardiac catheterization 8 hours ago whose vital signs have been stable for the last 2 hours a client with diabetes whose fingerstick blood glucose was 90 mg/dL 1 hour ago a client diagnosed with asthma who just received a respiratory therapy treatment a client feeling sweaty and requesting antacid for stomach upset

a client feeling sweaty and requesting antacid for stomach upset Signs of indigestion and sweating can be signs of impending myocardial infarction that should be carefully assessed by the nurse. The client who had the cardiac catheterization has stable vital signs and should be reassessed after assessing the client with a potential impending myocardial infarction. The client who had respiratory therapy does not require immediate attention. The client with diabetes has a normal finger stick glucose level and does not require immediate attention.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate? muscle flaccidity of the lower extremities tremors in the fingers that increase with purposeful movement coughing when drinking liquids bilateral upper extremity weakness

coughing when drinking liquids In Parkinson disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. Early Parkinson disease is characterized by unilateral upper extremity weakness and tremors. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired, and coughing would indicate aspiration.

The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.

Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. SBAR communication stands for Situation, Background, Assessment, and Recommendation. The nurse must first state the nurse's name and location. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.