Basic Physical Assessment Prepu Questions
While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.
Lordosis is characterized by an accentuated curve of the lumbar area of the spine.
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 increase the PSA." "A prostate examination can possibly decrease the PSA." "It is easier for the client." "If the PSA is normal, the client will not have to undergo the rectal examination."
Correct response: "A prostate examination can possibly increase the PSA." Explanation: 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.
To evaluate a client's cerebellar function, a nurse should ask "Do you have any difficulty speaking?" "Do you have any problems with balance?" "Have you noticed any changes in your muscle strength?" "Do you have any trouble swallowing food or fluids?"
Correct response: "Do you have any problems with balance?" Explanation: 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 preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? "I am allergic to penicillin and midazolam." "I took my metformin this morning." "I am very claustrophobic in small spaces." "I have not been able to eat since yesterday."
Correct response: "I took my metformin this morning." Explanation: The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.
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 on the bed. What is the most appropriate response by the nurse? "Are you feeling all right?" "Tell me what you are feeling." "Do you need pain medication?" "Are you having pain in your leg?"
Correct response: "Tell me what you are feeling." Explanation: The nurse should ask the client to tell the nurse what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions like "Are you having pain?", "Do you need pain medication?", and "Are you feeling all right?" may block communication.
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "What does the pain feel like?" "Is the pain constant?" "How does the pain medication make you feel?"
Correct response: "What does the pain feel like?" Explanation: An open-ended question (one that cannot be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are closed-ended questions. Having the client describe how the pain medication makes them feel does not address the issue of the client's present statement of pain.
The nurse is caring for an infant receiving phototherapy. While monitoring strict intake and output for an 8-hour shift the nurse assesses three diapers weighing 50 grams, 80 grams, and 25 grams. The infant weighs 3.4 kg. How many mL/kg/hr is this infant's urine output? Round to the nearest whole number.
Correct response: 6 Explanation: It is important to monitor strict intake and output in infants receiving phototherapy. Urinary output should be a minimum of 1 to 3 mL/kg/hr. Grams are equivalent to milliliters, so 1 gram = 1 mL. This infant has 3 diapers weighing 155 grams = 155 mL. Divide this by 8 hours and the answer is 19.375 mL per hour. Divide it once again by weight and the calculation is 5.69, which can be rounded to 6 mL/kg/hr.
The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action? Assess the client's temperature. Evaluate the client's white blood cell count. Notify the health care provider. Clean with antiseptic material and re-dress the site.
Correct response: Assess the client's temperature. Explanation: 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 caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next? Remove the family from the room. Begin chest compressions. Call the rapid response team. Ventilate the client with a bag-mask device.
Correct response: Call the rapid response team. Explanation: The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube? Moist bright red stoma with a scabbed area on one side Copious fluid leakage from the stoma Raised red papules around the stoma Dark pink stoma without drainage
Correct response: Dark pink stoma without drainage Explanation: A normal stoma should appear dark pink to red in color and should have no drainage or scant crusty drainage around the feeding tube. Copious fluid leakage from the stoma is not normal, and may indicate the stoma has enlarged, the tube is cracked or dislodged, the balloon has deflated, or another complication. Raised red papules around the stoma can indicate a yeast or candida infection. Yeast grows in moist areas, such as under the external part of the gastric or jejunostomy tube. A bright red stoma could indicate infection, and a scabbed area on one side indicates tissue damage and is not a normal assessment finding.
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? Transport medical supplies to where casualties are being evaluated. 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. Contact and inform all registered nurses about the disaster to elicit their help in assisting with the casualties.
Correct response: Follow the formal written plan of action for coordinating the response of the hospital staff. Explanation: 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.
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 straight up. Grasp the auricle with the nondominant hand, and pull down and back. Grasp the auricle with the nondominant hand, and pull down and forward. Grasp the auricle with the nondominant hand, and pull up and back.
Correct response: Grasp the auricle with the nondominant hand, and pull down and back. Explanation: 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.
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? Skin color, warmth of extremities, and mental status assessment Emotional status, response to anesthesia, and social support systems Metabolic rate, orientation, and presence of reflexes Level of consciousness, pain level, and wound dressing
Correct response: Level of consciousness, pain level, and wound dressing Explanation: 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 of African descent is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which area would the nurse check for pallor in the client? hands face abdomen tongue
Correct response: tongue Explanation: In a client of African decent, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas may have heavy pigmentation.
The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output? measuring the formula before the child ingests it weighing the child before and after feeds weighing the diaper before and after micturition monitoring the amount of time for breast feeding
Correct response: weighing the diaper before and after micturition Explanation: 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.
While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.
Explanation: Lordosis is characterized by an accentuated curve of the lumbar area of the spine.
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? increased sensitivity to glare nails are thickened, brittle, and yellow urine output of 600mL/24 hours lower peripheral pulses +1 bilaterally
Correct response: urine output of 600mL/24 hours Explanation: 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.
A school nurse is performing an otoscopic examination on an elementary student who states ear pressure. If the nurse suspects a potential diagnosis of otitis media, at which location would the nurse confirm the diagnosis?
Otitis media is a middle ear infection located between the tympanic membrane and the inner ear. When an infection occurs, pressure increases, causing a bulging and red appearance of the tympanic membrane. Rupture of the tympanic membrane can occur.
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse? Position the client on the side. Withhold food and fluids. Introduce a nasogastric (NG) tube. Insert an oral airway.
Correct response: Withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse would withhold food and fluid until the client's gag reflex returns. The client would be placed in an upright position. There is no indication that oral airway placement would be appropriate or that an NG tube is needed.
When percussing a client's chest, what should the nurse expect to hear? dullness tympany hyperresonance resonance
Correct response: resonance Explanation: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.
The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? pulse rate within 6 bpm of resting pulse after 3 minutes of rest diastolic blood pressure increased by 7 mm Hg respiratory rate decreased by 5 breaths/minute pulse rate increased by 20 bpm immediately after the activity
Correct response: respiratory rate decreased by 5 breaths/minute Explanation: The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest.
When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include increased coronary artery blood flow. decreased posterior thoracic curve. delayed gastric emptying. decreased peripheral resistance.
Correct response: delayed gastric emptying. Explanation: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.
Serum Osmolality : 325mmol/kg h20 Normal Range: 275-295 Platelet Count: 122 Normal Range: 150-400 x10^9/L Serum sodium: 122 mmol/L Normal Range: 135-145 Urine specific gravity: 1.041 Normal Range: 1.003-1.035 An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms? platelet count urine specific gravity serum sodium serum osmolality
Correct response: serum sodium Explanation: This client is exhibiting behaviors and symptoms associated with hyponatremia caused by water intoxication; the nurse would expect to find confirmation of a low serum sodium level by checking the electrolyte levels. The nurse would expect this client's serum osmolality and urine specific gravity to be low, not high.The platelet count is not relevant as there is no correlation between sodium levels and platelet counts.
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? urine output of 90 mL over the past 6 hours a core body temperature of 97.9° F (36.6° C) confusion when listening to explanations of procedures polydipsia
Correct response: urine output of 90 mL over the past 6 hours Explanation: Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.
A nurse is assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action? eupnea, oxygen saturation of 95%, and orthopnea pallor, hypotension, and bradypnea decreased pulse rate, increased blood pressure, and capillary refill time of 4 seconds increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis
Correct response: increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis Explanation: This combination of symptoms indicates hypoxia. The other choices are incorrect and are not indicative of hypoxia.
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? "If the PSA is normal, the client will not have to undergo the rectal examination." "It is easier for the client." "A prostate examination can possibly decrease the PSA." "A prostate examination can possibly increase the PSA."
Correct response: "A prostate examination can possibly increase the PSA." Explanation: 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 must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client? normal skin turgor is moist and boggy dehydration causes the skin to appear edematous and spongy overhydration causes the skin to tent inelastic skin turgor is a normal part of aging
Correct response: inelastic skin turgor is a normal part of aging Explanation: 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.
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 rhythm pulse pressure pulse deficit
Correct response: pulse deficit Explanation: 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.
The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? "I took my metformin this morning." "I am very claustrophobic in small spaces." "I have not been able to eat since yesterday." "I am allergic to penicillin and midazolam."
Correct response: "I took my metformin this morning." Explanation: The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.
What should the nurse include in the teaching plan for the family of a newborn receiving home phototherapy? Select all that apply. "It is okay for your newborn to wear a light T-shirt when under the lights." "Record your newborn's temperature, weight, and fluid intake daily." "The lights should be 12 to 30 inches (30 to 76 cm) above your newborn." "Keep your newborn under the lights at all times." "Make sure your newborn's eyes are covered well when under the lights."
Correct response: "The lights should be 12 to 30 inches (30 to 76 cm) above your newborn." "Record your newborn's temperature, weight, and fluid intake daily." "Make sure your newborn's eyes are covered well when under the lights." Explanation: In home phototherapy, lights should be kept 12 to 30 inches (30 to 76 cm) from the newborn. The caregiver should record the newborn's temperature, weight, and fluid intake daily. The newborn's eyes should be covered well under the lights. The newborn does not have to stay under the lights all the time. The newborn can come out for feeding and bonding. The newborn should be naked except for a diaper when under the lights.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 10 minutes every 20 minutes every 5 minutes every 15 minutes
Correct response: every 15 minutes Explanation: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
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." "Have your child take aspirin for a few days to see if the stiffness is relieved." "There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." "It is normal to have aches and pains, so your concern is probably unwarranted."
Correct response: "There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." Explanation: 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.
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? ineffective breathing pattern alteration in urinary elimination altered cardiac functioning alteration in level of consciousness
Correct response: ineffective breathing pattern Explanation: 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.
Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which would be the best response by the nurse? "It's fortunate that you came into the clinic today and this was caught this during your routine examination." "We will need to reevaluate the blood pressure because your age places you at a high risk for hypertension." "You have no need to worry. Your blood pressure is probably elevated because you are in the physician's office." "You will need to have your blood pressure reassessed before a diagnosis can be made."
Correct response: "You will need to have your blood pressure reassessed before a diagnosis can be made." Explanation: Hypertension is confirmed by at least two measurements greater than 129/80 mm Hg and taken on two separate occasions. The nurse should provide factual information to the client, not provide false hope.
Which statement heard during shift report identifies an important priority for action? A postoperative client has not voided for 5 hours after surgery. A client is reluctant to ambulate on the evening of surgery. A postoperative client's pulse has been increasing, and the blood pressure is decreasing. A postoperative client is drowsy and slow to respond when the analgesic is at its maximal effect.
Correct response: A postoperative client's pulse has been increasing, and the blood pressure is decreasing. Explanation: This indicates that the status of the client is rapidly changing. When there is an increase in the pulse postoperatively, this could indicate hemorrhage with the body compensating. When the blood pressure is decreasing, this could indicate that the body is now decompensating. Each of the other postoperative situations would represent a normal finding.
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? 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. Administer an antiemetic to reduce the nausea, and send the client to physiotherapy.
Correct response: Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Explanation: 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.
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 rapid response team (RRT)/medical emergency team. Call the PACU. Call the health care provider (HCP). Call the respiratory therapist.
Correct response: Call the rapid response team (RRT)/medical emergency team. Explanation: 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 nurse is assessing a postoperative client. Which information would the nurse document as subjective data? Client's pulse measures 84 beats/minute. Client's incisional dressing shows a small amount of sanguineous drainage. Client's bowel sounds are hypoactive in four quadrants. Client reports incisional pain as a level 3 on a pain scale of 1-10.
Correct response: Client reports incisional pain as a level 3 on a pain scale of 1-10. Explanation: Subjective data come directly from the client and are usually recorded as direct quotations that reflect the client's opinions or feelings about a situation (what the client says). The client's report of pain as level 3 on a scale from 1-10 is the client's description of the pain. Vital signs, bowel sounds, and incisional drainage are considered objective data (what the nurse observes).
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? 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. 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.
Correct response: Follow the formal written plan of action for coordinating the response of the hospital staff. Explanation: 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.
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. Obtain the child's vital signs. Institute droplet precautions. Ask the parent about medication allergies.
Correct response: Institute droplet precautions. Explanation: 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 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? Emotional status, response to anesthesia, and social support systems Metabolic rate, orientation, and presence of reflexes Level of consciousness, pain level, and wound dressing Skin color, warmth of extremities, and mental status assessment
Correct response: Level of consciousness, pain level, and wound dressing Explanation: 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 is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb to the hips. What should the nurse do next? Select all that apply. Notify the family of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Notify the health care provider (HCP) of the change. Have the client perform ankle pumps.
Correct response: Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Explanation: A client who has been admitted for numbness and tingling in the lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The HCP must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.
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? Reassure the client that this is a normal voiding pattern. Administer the prescribed analgesic, and repeat the client's vital signs in 20 minutes. Offer the client a warm compress, and observe for worsening discomfort. Perform a bladder scan, and obtain an order for urinary catheterization.
Correct response: Perform a bladder scan, and obtain an order for urinary catheterization. Explanation: 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.
A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness? Press firmly with one hand, release pressure while maintaining fingertip contact with the skin, and note any increased tenderness on release. Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release. Use the palm of one hand to press deeply over the affected area and note any increased tenderness. Use light palpation over the affected area and note any increased tenderness.
Correct response: Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release. Explanation: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The nurse doesn't use light palpation or deep palpation or maintain fingertip contact with skin to elicit rebound tenderness.
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next? Tell the assistant to change thermometers and retake the temperature. Promptly assess the client for potential perforation. Ask the assistant to bathe the client with tepid water. Plan to give the client acetaminophen to lower the temperature.
Correct response: Promptly assess the client for potential perforation. Explanation: A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a health care provider's (HCP's) prescription; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.
A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? Because the adolescent is a minor, inform her parents about her medical history. Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record. Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor. Respect the adolescent's wishes and maintain her confidentiality.
Correct response: Respect the adolescent's wishes and maintain her confidentiality. Explanation: The nurse should respect the rights of minors who do not want parents informed of medical situations; the nurse should not tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for healthcare visits involving pregnancy, abortion, or sexually transmitted diseases.
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? Avoid coitus for 10 days after a slight rise in temperature. 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).
Correct response: Take her temperature at the same time every morning before getting out of bed. Explanation: 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.
A client from Mexico has bacterial pneumonia and has a temperature of 102°F (39°C). The client has been treating the infection by drinking milk. How should the nurse interpret the client's method of self-treatment? The client has confusion from the fever. The client is taking the milk as a laxative. The client needs a referral to a dietitian. The client is using the hot disease concept.
Correct response: The client is using the hot disease concept. Explanation: The nurse interprets the client's statement as use of the hot disease concept in the Mexican culture, where the belief of a hot and cold balance of the body exists. A hot disease such as an infection is treated with the opposite, a cold food such as milk. The nurse should focus on the cultural differences and be sensitive to the cultural diversity.
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 reported feeling dizzy and weak and perspired profusely. The client's pulse and respiratory rates increased moderately during ambulation. The client's pulse and respiratory rate returned to baseline 1 hour after activity. The client's head was down, gaze was cast down, and toes were pointed outward.
Correct response: The client's pulse and respiratory rates increased moderately during ambulation. Explanation: 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.
Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected? The client requests a strong analgesic for pain. The client maintains bed rest. There is no bleeding at the aspiration site. There is redness and swelling at the aspiration site.
Correct response: There is no bleeding at the aspiration site. Explanation: 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).
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse? Withhold food and fluids. Insert an oral airway. Introduce a nasogastric (NG) tube. Position the client on the side. SUBMIT ANSWER
Correct response: Withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse would withhold food and fluid until the client's gag reflex returns. The client would be placed in an upright position. There is no indication that oral airway placement would be appropriate or that an NG tube is needed.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do? 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. 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.
Correct response: 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. Explanation: 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.
The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? a 3-year-old with a cardiac disease receiving a platelet transfusion a 4-year-old with chronic graft-versus-host disease who is incontinent a 5-year-old who received chemotherapy one week ago, admitted with a decreased level of consciousness and temperature of 101°F (38°C) a 2-year-old with immunodeficiency disease receiving chemotherapy
Correct response: a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.
The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? a 3-year-old with a cardiac disease receiving a platelet transfusion a 5-year-old who received chemotherapy one week ago, admitted with a decreased level of consciousness and temperature of 101°F (38°C) a 4-year-old with chronic graft-versus-host disease who is incontinent a 2-year-old with immunodeficiency disease receiving chemotherapy SUBMIT ANSWER
Correct response: a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.
The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? a 4-year-old with chronic graft-versus-host disease who is incontinent a 5-year-old who received chemotherapy one week ago, admitted with a decreased level of consciousness and temperature of 101°F (38°C) a 3-year-old with a cardiac disease receiving a platelet transfusion a 2-year-old with immunodeficiency disease receiving chemotherapy
Correct response: a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.
Which client should the nurse assess first? a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain
Correct response: a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.
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. reaction to the allergen severity of the allergy allergies to items other than medications, such as foods and animals favorite foods allergies to any medications siblings with allergies
Correct response: allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy Explanation: 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.
For which client is the nursing assessment of pain most likely to result in undertreatment? a Asian American client who requests medication for pain following abdominal surgery a black adult who has a client-controlled analgesic I.V. following cardiac surgery an older adult who grimaces and states no pain after a gastrostomy tube placement a young adult who vomits and keeps eyes closed during a migraine headache attack
Correct response: an older adult who grimaces and states no pain after a gastrostomy tube placement Explanation: Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled.
A client reports abdominal pain. Which action allows the nurse to investigate this complaint? assessing the painful area first checking for warmth in the painful area using deep palpation assessing the painful area last
Correct response: assessing the painful area last Explanation: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when the nurse will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.
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? bananas, rice, applesauce, and toast milk, custard, and vanilla ice cream broth, gelatin cubes, and tea a bland diet tray
Correct response: broth, gelatin cubes, and tea Explanation: 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.
A nurse is assessing a client who is postoperative and unable to verbally answer questions. Which non-verbal behavior(s) should the nurse interpret as the client having pain Select all that apply. restlessness drowsiness moaning grimacing clenching
Correct response: clenching restlessness grimacing Explanation: Clients having uncontrolled pain often become anxious and restless as a response to the pain. Facial movements like tightly closing the eyes, grimacing, and biting the lower lip are all indicators of pain. Clenching the teeth and biting the lower lip are indicators of pain. Moaning, groaning, crying, and screaming are vocalizations, and are not a non-verbal behavior. Drowsiness is not an indicator of uncontrolled pain.
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate? bilateral upper extremity weakness coughing when drinking liquids muscle flaccidity of the lower extremities tremors in the fingers that increase with purposeful movement
Correct response: coughing when drinking liquids Explanation: 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.
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate? bilateral upper extremity weakness tremors in the fingers that increase with purposeful movement coughing when drinking liquids muscle flaccidity of the lower extremities
Correct response: coughing when drinking liquids Explanation: 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.
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? additional fluid intake antihypertensive medication increased oxygen liter flow rate diuretic medication
Correct response: diuretic medication Explanation: 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.
In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? health habits, family relationships, affect, and thought patterns rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance general survey results, eating habits, and ability to perform activities of daily living breathing patterns, circulation patterns, and responses to hospitalization
Correct response: health habits, family relationships, affect, and thought patterns Explanation: A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors.
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? in the supine, sitting, and standing positions taking blood pressure on the left arm and again in 5 minutes on the right arm assessing at the beginning and the end of the examination ambulating the client around the room and then assessing blood pressure
Correct response: in the supine, sitting, and standing positions Explanation: 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.
The nurse is monitoring a client who is receiving moderate sedation for a procedure. The client begins to display signs of restlessness and agitation. What assessment does the nurse perform first? client's anxiety level pain scale oxygen saturation level of consciousness
Correct response: oxygen saturation Explanation: When a client has received sedation, hypoxemia is a potential complication and should be suspected and assessed for immediately at the first signs of restlessness and agitation, as these can be early signs of hypoxemia. Hypoxemia can cause rapid decompensation and lead to respiratory or cardiopulmonary arrest if not rapidly identified and corrected. Fear and pain are also possible causes of restlessness and agitation, and should be assessed for, but not until after the nurse has ascertained that the client is not hypoxemic. The level of consciousness will be altered due to the moderate sedation and being too alert could be a sign of undersedation. This should be assessed but is not a priority over the oxygen level.
A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? vesicles papules plaque pustules
Correct response: vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.
