Fundamentals and health assessment final
A nurse is providing discharge teaching for a client who requires home oxygen therapy which of the following statements should the nurse identify as an indication that the client needs further teaching
"I will wear synthetic clothing and woolen socks when using my oxygen"
Which question is an example of an open ended question
"What were you doing when you felt the pain?"
Intradermal injection
10 to 15 angle
Vastis lateralis injection
2ml
Ventral gluteal injection can only take
3 mL
Intragluteal insertion
3 mL max
Intramuscular
90°
For which patient is a focused Health history most appropriate
A patient admitted to the hospital with vomiting and abdominal pain
A student nurse is helping the precepting nurse collect and taken output at a long-term care facility which of the following does the student nurse collect for the nurse
All fluids consumed by a patient IV fluids urine output tube feeding that has been given through the kangaroo pump nasogastric tube output
How do nurses best assess a patient's pain
By asking the patient rate the pain being experienced
A nurse is preparing to transfer a client from a bed to a chair which of the following action should the nurse take first
Determine if the client can bear weight
What part of the stethoscope does nurses use to auscultate the chest
Diaphragm of the stethoscope
An example of a health promotion question included in the health history is:
How often are you exercising?
The assessment technique utilized for listening to the abdomen
Inspection auscultate palpitation and percussion
The assessment technique are utilized in which order except for when assessing the abdomen
Inspection palpitation percussion auscultation
A nurse needs to lift a box in a supply room which of the following action should the nurse take to prevent an injury due to lifting
Keep the box close to the body as he lifts
What data does the nurse document underneath patient health history
Last tetanus shot in 2009 had chickenpox as a child
Deltoid site arm
Less than 1ml
What is the most important nursing action to reduce transmission of organisms prior to inhalation of the physical assessment
Perform hand hygiene
High risk drugs
Potassium insulin nitro chemo heparin requires two nurses for verification
18 gauge is used for
Surgery and blood administration
A nurse witnesses a client begin to experience a seizure which of the following actions taken by the nurse demonstrates appropriate care for the client
The nurse cradles the clients head in lap
Which example best characterizes a patient's race
The patient and his family have blonde hair and fair skin
16 gauge device is used for
Trauma patients
When examining a patient the nurse remembers to follow to the principles of standard precautions
Wear gloves when in contact with the patient mucous membrane
In which situation is the nurse use of Close ended question most appropriate
When obtaining a history on an over talkative client
Subcutaneous abdomen thighs
45 to 90
A nurse is assessing a client radial pulse and determines that the pulse is regular which of the following action should the nurse take
Assess the apical pulse for one minute
Inners is admitting a client who has a wound infection with vancomycin resistant enterococci Which of the following types of precaution should the nurse plan to initiate
Contact
The nurse suspects an irregularity in the rhythm of a patient's radial pulse which of the following appropriate actions for the nurse to take it this time
Count the patients apical pulse for one minute
A nurse is admitting a client who has pertussis which of the following types of transmission based precaution should the nurse take
Droplet
A nurse is caring for a client who wears antiembolic stocking so the nurse removes them at which time interval to assess for redness warmth and tenderness
Eight hours
When caring for a client who has a decreased level of consciousness who is receiving continuous internal two feedings for a small board tube because of an ability to swallow effectively which of the following action should the nurse take
Elevate the head of the clients bed 30 to 45°
A nurse is caring for a client and suspects a possible thrombosis in the left calf which of the following actions does the nurse take
Elevate the leg and do not apply pressure or massage to suspected area
How is subjective data collected
From the patient
A nurse provides care to a client who is on a clear liquid diet which of the following choices should be included
Fruit flavored gelatin chicken broth
And nurses providing care for a patient with hepatitis C which personal protective equipment does the nurse done
Gloves only
A nurse is caring for a client who is prescribed bed rest of the plan of care indicates the client should perform isometric exercises every two hours which of the following action should the nurse take as directed by the plan of care
Instruct the client to tighten muscle groups for a short period and relax
How does a nurse accurately palpitate carotid pulses
One finger is placed along the right and then left medial sternocleidomastoid muscle
A nurse is planning care for a client who has a large abdominal wound from a surgical procedure the nurse should encourage the client to eat which of the following foods are naturally high in vitamin C to promote wound healing
Oranges
What are the characteristics of one's culture
Systems of beliefs and practices
What does the S2 heart sound represent
The closure of the aortic and pulmonary valves
A nurse is assessing a clients cardiovascular system to palpitate for unexpected pulsations in the pulmonic area at which anatomical location should the nurse place her fingers
The second intercostal space
A male patient is very talkative and shares much information that is not relevant to The history or The admission which action by the nurse Is most appropriate
Use close ended questions
Z track
Zigzag pattern to keep medication within body
Nurse is applying heat therapy to a client with shoulder pain the nurse is careful to assess for any damage to the skin and plans to remove the source of heat therapy at which time in bowl
15 to 30 minutes
The nurse is caring for a group of clients which of the following clients should the nurse identify as having an increased risk of aspiration while eating
A client who has had a CVA a client who is prescribed a thicken liquid diet a client who has a new NG tube
A nurse is caring for a group of clients which of the following clients should the nurse identify as having an increase risk of aspiration while eating
A client who is in a rehabilitation facility following a CVA (stroke) 94-year-old client with dysphagia ( trouble breathing) a client receiving tube feedings through a nasogastric tube a client who passes a speech therapy evaluation to have a diet but it's not allowed using a straw
The nurse is caring for four clients the nurse knows that which of the following clients is at higher risk for falls
A client who is taking furosemide twice a day
When is it the most appropriate to take a rectal
A comatose patient
A female Korean patient accompanied by her husband and son comes to the emergency department (ED) complaining of abdominal pain. The patient speaks and understands Korean only. Which person is the appropriate choice for the nurse to use to get a history from this patient?
A female interpreter who speaks Korean and English and is available by phone
Which situation represents a screening assessment
A hospital sponsors a Health fair at a local mall and provides cholesterol and blood pressure checks to Mall patrons
Which patient should be expected to experience acute pain
A patient who had a domino surgery eight hours ago
Well also taking a clients heart sounds the nurses here turbulence between the S1 and S2 sounds the nurse should document this finding as which of the following
A systolic murmur
A nurse is admitting a client who has tuberculosis in a productive cough which of the following types of isolation precaution should the nurse initiate for the client
Airborne
The definition of pain is
An unpleasant sensory or emotional experience associated with actual or potential tissue damage
A nurse is precepting a student in caring for a client who constantly restricts nutrition and repeatedly takes action to prevent weight gain which disordered eating pattern does the student nurse recognize a patient has
Anorexia nervosa
Nociceptive pain can be one of the following descriptors
Arises from somatic structures such as bone joint or muscle incomes from the activation of neutral systems
During an assessment the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck which of the following actions by the nurse is appropriate
Ask the patient about the item and it's significance
A nurse is interviewing a male patient who states that they have not had a tetanus immunization in about 15 years because he has had a bad reaction to the last tetanus shot what is the most appropriate Response by the nurse
Ask the patient to describe the bad reaction
A patient tells the nurse that her religion prohibits her from eating food prepared outside of a special kitchen what is the nurse is appropriate action to meet this patient's needs
Ask the patient to describe the requirements for the special kitchen
A Client immediately requires a nasogastric tube per feeding due to dysphasia which of the following actions does the nurse take immediately after inserting a tube
Aspirate gastric content to measure pH
When caring for an elderly client who has been on bedrest for a prolonged amount of time the nurse understands that this client is at risk for skin breakdown and takes which of the following actions
Assesses for changes in skin color assesses the scapular sacrum elbows and knees changes the bedding of the client when incontinent of bowel or bladder positions a client with corrective devices
A nurse is caring for a client who is cognitively impaired and repeatedly pulling on his NG tube which of the following action should the nurse take before requesting a prescription for restraints
Assist the client with toileting at frequent intervals use a electronic positioning sensitive device provide diversionary activities for the client involve the family and the clients care
A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium which of the following foods should the nurse instruct the client to avoid
Bananas oranges milk spinach apricots prunes soy lima beans kidney beans baked potatoes
A nurse notices an assistive personnel preparing to deliver a food tray to a patient who practices the orthodox Jewish faith on the tray is roast beef dinner with nonfat milk which of the following action should the nurse take
Call the dietary department and ask for a kosher tray
A nurse received report from the off going nurse on a client who has a NG tube placed during the last shift the off going nurse states that there are 400 mL of output in the canister the oncoming nurse is doing a initial assessment and notices that the canister is still only contains 400 mL what is the priority action by the nurse after confirming it is at the same center meter mark as on insertion
Check the canister to make sure all the caps are closed and suction is on
A nurse is preparing to teach the community about the effects of long-term or prolonged immobility on the metabolic system which of the following does the nurse prepare to teach select all that apply
Decreased appetite and altered nutritional intake decreased muscle mass loss of weight reabsorption of calcium from bone
The nurse prepares to replace the nearly empty container of total parenteral nutrition TPN for a client when she finds that there has been a delay in receiving the next container of solution from the pharmacy which of the following solution should the nurse infuse until the next container of TPN solution becomes available?
Dextrose 10% in water
A male patient tells the nurse that he rarely sleeps more than four hours a night and and has not experienced any problems because of lack of sleep What responses most appropriate
Did I understand that you sleep four hours every night
Which question is the most appropriate to learn about a patient's religious practice
Do you have any specific religious or spiritual beliefs
Inners is planning care for a client who has become increasingly anxious and confused which of the following action should the nurse include to avoid the use of physical restraints
Ensure effective pain management attend to the clients needs for toileting assign the client to a room near the nurses station orient client frequently to the environment
How do nurses assessing the pain of neonate or adults with dementia or decreased level of consciousness
Examine the patient for a possible causes of pain identify any psychological signs of pain ask family or caregivers what indicators they think may indicate the patient's pain
Which activity illustrates the concept of primary prevention
Exercising three times a week
A nurse is caring for a client who has impaired mobility which of the following supports Devices should the nurse plan to use to prevent the client from developing plantar flexion contractures
Footboard
A nurse is assisting an older adult client who sometimes loses her balance when walking which of the following devices should the nurse use when helping the client ambulate
Gait belt
A nurse is removing personal protective equipment after giving direct care to a client who requires isolation which of the following PPE items should the nurse remove first
Gloves
The new nurse understands the proper donning and doffing of personal protective equipment is important when a representative of the joint commission ask a nurse to explain the proper PPE order the nurse correctly replies with
Gown mask goggles face shield gloves
A nurse is caring for a client who has active pulmonary TB the client requires airborne precautions and is receiving multi drug therapy which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest X-ray
Have the client wear a mask
A nurse is instructing a client who has an injury of the right lower extremity about the use of a cane which of the following instruction should the nurse include
Hold the cane in the left hand keep two points of support on the floor and place the key in 15 to 25 MCG's in front of the feet before advancing
A nurses getting history on a patient who is disabled due to rheumatoid arthritis which question will provide data about the patients functional abilities
How has the arthritis affected your daily life
A nurse is teaching a client who has a history of falls about home safety which of the following statements should the nurse identify as an indication that the client understands the instructions
I will place a bath seat in my shower to be used when I bathe
Which statement or question does a nurse use during a introduction phase of an interview
I'm here to learn more about the pain you're experiencing
A nurse is reviewing the medical records of a client who has a urinary track infection which of the following findings should the nurse recognize as a risk factor
Immobility
Thrombophlebitis Can be described
Inflammation of a vein that may or may not be accompanied by a clot
To document the publication of a pulse the nurse is correct and making with notation about the rhythm
Irregular rhythm
A patient reports right shoulder pain that comes and goes as the chief complaint during the physical examination and patient ask why the upper right abdomen is being examined for shoulder pain what is the appropriate response from the nurse
It does seem odd but the gallbladder does not have pain receptors of its own so the pain shows up in the shoulder
A nurse is presenting a class about fall prevention to a group of assisted living residence which of the following statements by a resident best indicates an understanding of the teaching
It is a good idea to use the handrails in the bathroom
A nurse is getting ready to insert an NG tube into a patient who is unable to efficiently swallow due to a CVA the nurse practices the ethical principle of versatility (telling truth) and informed the client that the procedure is very uncomfortable which of the following does the nurse communicate with the patient prior to the insertion of the NG tube
It means for the client to communicate stress beyond discomfort
A nurse is preparing to apply restraints to a client to prevent her from pulling out an IV catheter which of the following action should the nurse take
Keep the padded portion of the restraints against the wrist
The nurse is preparing to assess the dorsalis pedis artery What is the correct location for palpitation
Lateral to the extensor tendon of the great toe
Nurse is assisting with transferring a client from the bed to the wheelchair which of the following action should the nurse take
Lock the wheels of the bed and the wheelchair
A nurse is assisting a client during ambulation which when the client starts to fall which of the following actions should the nurse take
Lower the client to the floor
A nurse is caring for a client who requires droplet precautions which of the following personal protective equipment should the nurse wear when setting up the clients meal tray
Mask
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis which of the following action should the nurse take
Measure from the heel to the popliteal space
The nurse is preparing the room for the dermatologist the nurse knows that the patient may have a fungal infection on the left leg what tool is not part of the set up for this assessment
Monofilament
A client smoking in the bathroom has dropped a cigarette butt in a waste basket which begins to smaller which of the following actions should the nurse do priority
Move any clients in the immediate vicinity
And nurse is teaching a client about crutch walking using the three point gate which of the following statements by the nurse should be included in the teaching
Move both crutches forward while standing on the unaffected leg and lift and swing your body past the crutches
A nurse is teaching a client about crutch walking using a three point game which of the following statements by the nurse should be included in the teaching
Move both crutches forward while standing on the unaffected leg then swing your body pass the crutches
A nurse is completing a client health and physical examination which of the following information should the nurse consider a subjective data
Nausea
Assessment of circular motion and sensation is done every eight hours in a patient recovery from a laminectomy three days after surgery and the patient had the surgery for constant lower back pain now on day three of the patient has a burning sensation on the lateral edge of the right foot is best described as
Neuropathic pain
A nurse is caring for a client who has CDF infection which of the following cleansing agent should the nurse use for hand hygiene
Non-antimicrobial soap
The nurse reviews an assessment of a patient peripheral pulses and notices that the documentation states that the radio pulses are 2+ the nurse recognizes that this reading indicates what type of pulse
Normal
A nurse is explaining cardiovascular alterations that can occur with prolonged immobility the nurse correctly explains to the client which of the following alterations can occur
Orthostatic hypertension venous stasis increased risk of blood clots (thrombosis)
Inhalation of intravenous access can be in painful experience for the patient as the needle is inserted into the skin the patient is calm however the patient pulls the hand away when the needle pierces the vein the time that the person enters the pain before outwardly responding is known as
Pain tolerance
A patient has chronic back pain for several years on assessment the nurse notes that the patient sits quietly in a chair read a book talks with a companion it does not appear to be in pain when questioned The patient rates the pain as a six on a scale of 0 to 10 how does the nurse interpret this data
Patient may not have the same objective response to chronic pain because of the compensation overtime
Inners is providing education to a patient who is prescribed insulin the client tells the nurse that he does not want to take it the nurse understands the rights of the medication administering incorrectly documents which of the following actions in the chart
Patient refused medication education provided by nurse patients to refuse medication
What is an example of data a nurse Collect during a physical examination
Patient's lack of hair and shiny skin over both shins
22 to24 gauge needle is used for
Patients who have medical issues and are stable
A nurse is assisting a client who has required strict bed rest for one week which of the following findings should the nurse identify as an indication that the client is ready to ambulate
Perform active range of motion exercises of all extremities
Which of the following actions by the nurse results in the patient's blood pressure measurement being falsely high
Positioning the patient's arm above the level of the heart using a blood pressure cuff that is too narrow for the patient's upper arm wrapping the blood pressure cuff to loosely
Staff development educators are responsible for assisting staff nurses in being adequately prepared to perform their duties as they care of her patients for many different cultures and backgrounds as the educator works with a new nurse from the Philippines the educator will include
Practice in assessing patient's personal beliefs and practices
A nurse is admitting a client who reports anorexia and is experiencing malfunction which of the following laboratory findings should the nurse expect to be altered
Protein labs
What findings does the nurse expect when assessing the cardiovascular system of a healthy adult
Pulse of smooth contour with +2 amplitude S1 plus S2 present with regular rhythm and warm elastic turgor
A client has orders for a dysphasia diet which of the following does the student nurse know are safe to be the client
Puréed food
Where can a nurse assess for a pulse
Radial carotid popliteal post tibial
A patient tells a nurse at the clinic I can never seem to get warm lately and feel tired all the time The nurse records these data is under which part of the health history
Reason for seeking care
To test deep tendon reflexes nurses which instrument
Reflex hammer
A nurse is caring for a client who has congestive heart failure and is on a 1200 mL per 12 hour shift fluid restriction which action does the nurse take in order to ensure the client does not have more than fluid allowed
Remove the water picture from the bedside educate the patient and the family member visitors about the food restriction and reasoning for the restriction record all oral intake
Which direction of blood throw through the heart is best described by these
Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium and left ventricle
Before administering medication for the first time the student nurse understands the rights of medication administration which of the following are included in the rights of medication administration
Right to refuse right medication right dose right patient
A nurse is teaching a new group of assistive personnel about the importance of hand hygiene which of the following statements should the nurse include
Rub all surfaces of your hands with alcohol rub for 20 to 30 seconds
A nurse is assessing a patient and she places her bell of the stethoscope at the apex of the heart with the patient in a left lateral position what heart sound is she listening for
S4
A newly licensed nurse is applying prescribed wrist restraints on a client which of the following action should the nurse take
Secure the restraints using a quick release tie
A client is receiving to beating through a NG tube and has had six episodes of diarrhea in the last 24 hours the nurse understands her client may not be tolerating the tube feeding and performs which of the following actions
Slow the installation rate notify the provider collaborate with a dietitian
What patient information does the nurse document in the patient physical assessment
Slurred speech
A patient's plan of care includes the goals of increasing mobility and ambulating the patient 20 feet this shift which of the following provides a nurse guidance when establishing goals for the clients plan of care
Smart Specific measurable attainable realistic timely
A patient who had an amputation of his lower leg comes to the clinic with a complaint of pain he asked how I can be feeling pain in my foot my foot is gone what is the appropriate response of the nurse
Stimulation of nerves from your legs and pulses to the brain so that you still feel pain even though your leg is still gone
A client is receiving tube feedings through a small bore NG tube the nurse suspects the client has aspirated on the tube feedings which is the nurses priority action
Stop the tube feed
A nurse teaches a old adult about measures to prevent constipation which of the following should be included
Take docusate/Colace as prescribed
A nurse is caring for a client who is at risk for falls which of the following action should the nurse take
Teach the client to use the call light keep the bed and the lowest position place a fall risk identification band on the client
During the history the patient states that she does not use many drugsWhat is the most appropriate response for that answer
Tell me about the drugs you're currently using
Which statement by the nurse represents a patient centered interview
Tell me about the symptoms that you've been having
A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of persistent headaches the patient tells the nurse that the medication is prescribed by the tribe leader have done some good what is the appropriate response of the nurse at this time
Tell me about these medicines and how often do you use them
A nurse is interviewing a patient who was diagnosed with type two diabetes mellitus 6 months ago since that time the patient has gained weight and her blood glucose remains high The nurse suspects that the patient is noncompliant with her diet what response by the nurse enhances data collection in Thai situation
Tell me about what foods you eat and the frequency of your meals
A nurse is teaching a patient how to manage chronic COPD this intervention is an example of which level of health promotion
Tertiary prevention
A nurse is assessing a client's ability to ambulate with crutches using a three point gate which of the following action should the nurse identify as a risk to the client safety
The client places partial weight on the affected leg
What does the S1 heart sound represent
The closure of the tricuspid and mitral valve
A nurse is performing a cardiac assessment identify where the nurse should place the stethoscope to auscultate the clients apical pulse
The nurse should also take the clients apical pulse over the apex of the heart located on the fifth intercostal space
Where does a nurse place a stethoscope to also take the mitral valve area choose the letter that corresponds to the correct stethoscope placement
The nurse should place a stethoscope at the location of the tricuspid valve area fourth intercostal space
For which person is a shift assessment indicated
The person who had abdominal surgery yesterday
For which patient is an episodic or follow up assessment indicated
The person who is beginning rehabilitation after a knee replacement
Which statement is correct regarding taking or interpreting axillary temperatures
The thermometer is left in place for no longer than three minutes
The student nurse is helping to care for a client who is on a clear liquid diet the nurse correctly explains to the precept the nurse that clear liquid diet are prescribed for which of the following
To rest the G.I. track preoperatively right after a surgery too much nausea vomiting diarrhea
A nurse is providing oral care for a client Who is Immobile which of the following action should the nurse take
Turn the client on his side before starting oral care
Which nurse behavior indicates culturally competent care
Understand that there is diversity even among people in the same cultural group
A nurse is conducting a dietary assessment on a client who is on a vegan diet the nurse provides dietary teaching and should focus on high foods in which vitamin That may be lacking in vegan diets
Vitamin B
The patients reports having a persistent cough for the past 2 weeks and that cough disrupts sleep and has not been helped by over the counter medications which question is most appropriate for the nurse to ask
What other symptoms have you noticed related to the cough
A nurse at an extended care facility is instructing a class of AP about client use of assistive devices during ambulation which of the following instruction should the nurse give the AP about the clients use of a cane
When the cane moves he's should move the cane first
A nurse at a extended care facility is instructing a class of assistive personnel about client use of assistive devices during ambulation which of the following instructions should the nurse give the AP about the clients use of a cane
When the client moves he should move the cane first