NUR 306 Test 1 Chapter 1,2,3,4,5,10 Practice Questions

Which part of the nursing process includes the formulation of goals?

Planning

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words.

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

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

The diaphragm should be held firmly against the body part.

What must occur before a client will be willing to teach the nurse about her culture?

The nurse needs to establish rapport and trust

An instructor is reviewing the steps to obtain a radial pulse. The instructor determines that the teaching was successful when the students demonstrate which of the following?

Use of two middle fingers lightly applied to wrist area along the thumb side

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?

Using a moderate amount of eye contact

The nurse is preparing to interview a client through the use of an interpreter. Which approach should the nurse use for this interview?

face the client during the interview

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

focused

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.

The result of a nursing assessment is the

formulation of nursing diagnoses.

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

health maintenance

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

A client who practices the Hindu faith requires an intravenous line. The nurse understands the IV should be placed in which of the following locations to promote healing?

right hand

To give spiritual care to a client, it is not necessary for the nurse to

share the same religious beliefs as the client to provide effective spiritual care.

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom?

urinary

A client with a long history of back pain is scheduled for back surgery. The nurse obtains the client's health history. Which of the following statements by the client requires further investigation?

"I take medication to thin my blood."

A client asks to see his medical record (chart). How would the nurse respond?

"I will get your chart and provide you with privacy to read it.'

A nursing instructor is teaching nursing students about cultural competence. The instructor determines understanding when the students make which of the following statements?

"The nurse must be aware of the client's beliefs and values to provide high-quality care."

Which of the following would be most appropriate for the nurse to ask when beginning to assess a client's spirituality?

"What gives you hope or peace?"

When is it necessary for a nurse to change gloves?

(1) between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms and (2) when going from a contaminated area to a cleaner area

A nurse is assessing a community and determines that it is a small rural community with limited home health care services. The nurse should plan to address which other health care limitation(s) in the community? Select all that apply.

-long-term care -respite care -reimbursement -skilled nursing

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mm Hg

A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Ask the other nurse to read back what first nurse reported

The nurse receives the following report. A client was admitted for a left hip fracture following a fall at home. The client was diagnosed with osteoarthritis 7 years ago. The left leg is shorter than right. Ecchymosis noted over left hip and groin areas. Pedal pulses palpable and strong bilaterally. Patient reports a pain rating of 8. An orthopedic case management consult is needed. Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent?

Background

The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of:

Batch charting

The nurse is planning to assess for the presence of lower pitch sounds when examining a client's heart. Which item of equipment would the nurse use to make this assessment?

Bell of a stethoscope

A nurse assesses a 4-year-old boy who experiences gas, a stomachache, and diarrhea after consuming lactose products. The nurse recognizes the data as what type of biological variation?

Biochemical

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.

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

Charting by exception-A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective data (followed by objective data, then validation, and then documentation)

During a spiritual assessment the nurse realizes that personal beliefs differ significantly from those of the client. What should the nurse do?

Continue with the assessment

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

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?

ED nurse

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.

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

Establish a baseline for the comparison of future health changes.

When beginning the collection of the client data base, which of the following would be most important for the nurse to do?

Establish a trusting relationship

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

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?

Family history

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

The nurse would use the tuning fork to assess for what?

Hearing loss

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?

Individual student interview and questionnaire

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection

Computerized charting is expensive but also has many benefits. One such benefit is:

It improves legibility.

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?

Measure the client's blood glucose four times daily.

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?

Mediterranean and Africa.

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?

Notify the rapid response team

A nurse is collecting data on a client's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "When did this pain start?" Which component of symptom analysis does this question represent?

Onset

Which of the following statements best describes alternative medicine?

Particular treatments are undertaken instead of biomedical treatments.

At a community town hall meeting in a small town, town members ask the nurse, "What is the purpose of a community assessment?" What is the best response by the nurse?

"A community assessment will help identify population health problems and factors contributing to them."

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?"

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?

"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?

"Could you describe how you perform self-breast exams?"

The nurse identifies which of the following as risk factors for spiritual distress?

-negative life changes -natural disasters -chronic illnesses

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?

A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Airway

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?

Ask the client if they have allergies.

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

The nurse is assessing a client. Which body area will the nurse use the diaphragm of the stethoscope to assess?

Heart sounds Breath sounds Bowel sounds

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.

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three clients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting?

It contributes to many potential errors.

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

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

A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details.

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.

The nurse has identified a problem with communication in the community upon completing her community assessment. Traditional communication may not be enough due to which of the following reasons?

Some do not speak or understand English.

During an interview, a client tells the nurse about spending time out of doors and hiking to connect with the earth and observe the activities of small animals. The nurse would document this client's hiking behavior as supporting:

Spirituality

A client has a pulse rate of 28 beats/15 seconds. How should the nurse document this finding?

Tachycardia

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider?

Use the SBAR model.

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

The nurse recognizes the goals and objectives of the Healthy People 2030 guidelines when creating a plan of care that addresses which client-centered goal(s)? Select all that apply.

living a healthy lifestyle disease prevention improving one's quality of life increasing the longevity of one's life

A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?

nutrition health pattern

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?

open-ended questions to allow full freedom of response

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

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention

The nurse in a community health clinic performs a comprehensive assessment on a new client. The 33-year-old male client is awake, alert, and moves all extremities well. Vital signs include: temperature, 101.2°F (38.4°C); heart rate, 100 beats/min; blood pressure, 90/60 mm Hg. The client reports burning when urinating. The client's last bowel movement was 2 days ago. Based on the client's findings, the nurse should follow up on...

temperature & burning during urination

The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client's cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability?

the Alzheimer's Association (AA)

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?

"How does that make you feel?"

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client?

-A list of all of the client's current medications -Onset and character of the clients chest pain -Date and location of the clients last blood pressure check

An adult Hispanic client presents to the ED with upper right quadrant abdominal pain. He is functionally illiterate in English. What principles should the English-speaking nurse follow when dealing with the client?

1. Limitations in English are not a reflection of intellectual functioning 2. Clients tend to think in their native language and translate, delaying their responses 3. Written information in the native language supports verbal communication

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?

All client information is private and confidential

A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?

An assessment flow chart

The nurse is collecting data from a client. Which of the following best reflects objective data?

Appearance

An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?

Assess the client's temperature by axilla

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

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

When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve client care?

Gaining relevant information about the client's spirituality.

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?

Gloves, mask, protective eye goggles, gown

The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?

L

During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?

Past history

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Secondary

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

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers.

The nurse is conducting a general survey of a client new to the clinic. In what part of the survey would the nurse assess the hair distribution on the client's body?

When assessing the skin

A nurse has just completed a community assessment for a small rural town. Some data collected include the following: 11.8% unemployment, lack of medical care services, median income below the national average. Based on the limited data given, which of the following is the best nursing diagnosis?

ineffective community coping related to unemployment

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect may be occurring with the client?

intimate partner violence

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 preparing for a focused assessment on a client reporting abdominal pain. In what order should the nurse perform the following actions? Place the actions in the correct order.

1. Wash hands prior to donning gloves. 2. Inspect the abdomen. 3. Warm stethoscope. 4. Auscultate abdomen. 5. Perform percussion. 6. Palpate the abdomen

The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?

Document the finding

The nurse reviews data about a community's vital statistics. Which information indicates a lack of services?

High death rates

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

Latex allergy

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

Meaningful use of electronic health records

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Repeating the measurement with a different sphygmomanometer and stethoscope

In which situation should a nurse perform an emergency assessment of a client?

Shortness of breath

Long-term care facilities in a community would be deemed adequate if which situation exists?

Sufficiently specialized care is available for local residents who cannot live independently.

The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?

The new mother may believe buying infant clothing before the delivery is bad luck.

A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?

Validation of data

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

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?

Wearing gloves to palpate the tongue and buccal membranes

A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a client. The student shows understanding of the difference between subjective and objective data by identifying the following as objective data.

decubitus on left heel