Chapter 3, 4, 8 Course Point Quizzes
A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?
50 mm Hg
A nurse is preparing to evaluate an older client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?
Braden scale
A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?
Bradycardia
During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?
Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.
Gloves Gown Face shield
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?
Orthostatic hypotension
A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?
Patient rated pain level as being a 5 using the rating scale.
A nurse observes that a client is out of breath from running up a flight of stairs just prior to conducting a general survey. What is the best action of the nurse?
Plan to take vital signs at the end of the assessment.
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?
Reading is erroneously high.
Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client?
Reading will be high
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following?
Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss.
A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
Skinfold calipers
A student nurse is performing a head-to-toe assessment on a new client. The nurse intervenes when which of the following is observed?
The bell of the stethoscope is used to auscultate bowel sounds.
Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?
The blood viscosity would be thinner, causing the blood pressure to decrease.
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap
Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing?
Tympanic
The nurse is performing a focused assessment on a client who reports several episodes of dizziness on standing. How should the nurse document the findings?
client states, "I have frequently felt dizzy when standing the past 2 weeks," heart rate 94, BP 105/70mm Hg, skin turgor elastic, voiding 3 liters/day.
A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?
color
While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing
A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?
explain to the client why the assessment is important and the possibility of missing important findings.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
it provides quick access to abnormal findings.
You should use the bell of the stethoscope when auscultating what type of sounds?
low-frequency sounds
The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:
orthostatic hypotension.
The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?
otoscope
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?
use as a drape
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
Student nurses are taking vital signs at a community screening clinic. The nursing instructor should intervene when the student nurse performs which of the following actions?
Applies the cuff to the right arm above the client's shunt location
Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
The nurse notes which of the following vital sign findings as an abnormal finding in an 88-year-old client?
Oral temperature of 37.6 °C (99.6 °F)
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?
Palpation
When assessing a client's pulse, the nurse should be alert to which of the following characteristics?
Rate, rhythm, amplitude and contour, and elasticity
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
Resonance
To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
How should the nurse place the ear of an adult when using the otoscope?
Up and back
A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record?
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?
1+
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
45 to 60
The nurse manager intervenes when which of the following is observed?
A nurse provides the spouse of a client access to the client's medical record.
A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?
Chronic obstructive pulmonary disease
A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?
Consult with a clinical instructor.
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
A nurse takes the vital signs on a new 35-year-old client: temperature 98.5° F (36.94° C), pulse 87 beats/min and regular, blood pressure 125/77 mm Hg on the right arm and 120/75 mm Hg on the left arm, and respiratory rate 16 breaths/min. What action should the nurse take?
Document normal findings.
The nurse would use what part of the hand when assessing temperature during palpation?
Dorsal surface
A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?
Eliminate distracting noises from the environment.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?
Explain the importance of the examination and the risks of breast cancer
The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?
Limit position changes as much as possible
During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?
Lungs
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
A nurse observes an unlicensed assistive personnel (UAP) taking a blood pressure reading on a client. The cuff wraps around the client's arm nearly twice. What is the best action of the nurse?
Obtain a smaller cuff for the UAP.
A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur?
Orthostatic hypotension
A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?
Snellen chart
A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?
Systolic pressure
Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?
Systolic pressure 180 mm Hg.
A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's occupation The client's family history of cancer The client's weight-lifting routine
A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?
The middle finger of one hand is placed on the body surface and the other middle finger strikes.
Which describes the nurse using the technique of percussion?
The nurse notes resonance over the individual's thorax.
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?
To determine whether a structure is filled with air or fluid or is a solid structure
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration?
Verify client allergies to medications.
A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse?
Verify whether the client has allergies.
The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?
Watch chest movement before removing the stethoscope after counting the apical beat
The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?
auscultation of the heart using the stethoscope bell
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
hyperresonance
Light palpation is most appropriate to assess the
inflamed areas of skin Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).
What information concerning a client's respirations should the nurse record after completing a general physical assessment
rate, rhythm, and depth of respirations taken for a full minute
What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
One disadvantage of the open-ended assessment form is that it
requires a lot of time to complete.
a new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse?
verify whether the client has allergies
A nurse performs a focused assessment on a client reporting increased shortness of breath. The nurse uses COLDSPA to learn more about the client's symptoms. Which statement(s) by the client would require verification? Select all that apply.
"I cannot lie flat when sleeping." "I started having shortness of breath a few weeks ago." "Walking upstairs and long distances increases my shortness of breath."
A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?
Arm
A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?
Blood pressure cuff is tightly fitted.
Universal precautions are primarily designed to protect the health care worker from what?
Blood-borne pathogens
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
Heart murmur
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
Limiting abbreviations to those approved for use by the institution.
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases.
When should the nurse perform hand hygiene? Select all that apply.
When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular
c, d, e, b, a
What action is appropriate for a nurse to perform when an irregular radial pulse is palpated on a client?
count the pulse for a full minute for an accurate rate
An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of
decreased body metabolism.
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
decreased range of motion in right shoulder
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing
deep palpation
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
