NURS 307: Health and Physical Assessment Exam 1

What is the acceptable respiration rate range?

12-20 breaths per minute

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. 5th intercostal space just medial to the mid clavicular line B. 2nd intercostal space to the left of the sternum C. 5th intercostal space to the left of the sternum D. 2nd intercostal space to the right of the sternum

2nd intercostal space to the right of the sternum ***The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

What is the acceptable pulse rate range?

60-100 beats per minute

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. "Ask your provider to prescribe epoetin before the surgery" B. "You should ask your provider about taking an iron supplements prior to the surgery" C. "Request a family member to donate blood for you" D. "Donate autologous blood before the surgery"

"Donate autologous blood before the surgery"

A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm bristled brush to remove loose skin." "The nurse will use scissors to open small blisters."

"I will be on a special shower table."

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image? A. "May I go with my family to the visitors lounge? B. "I'll see my friends when I get home." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."

"May I go with my family to the visitors lounge? ***This statement demonstrates a positive self-image. The client is asking to visit with her family in a public setting.

You are collecting subjective data prior to performing a skin assessment on a client. Which of the following responses requires additional investigation? A. "That birthmark on my thigh has always looked the same as it does now." B. "I notice that my freckles get darker in the summertime." C. "I have stretch marks on my abdomen from being pregnant." D. "One of my moles now has several colors on it."

"One of my moles now has several colors on it."

Place the following five key components of the nursing process in order of completion. Implementation Analysis Evaluation Assessment Planning

AAPIE Assessment Analysis Planning Implementation Evaluation

Name five of the key ethical principles involved in the nursing practice.

ABC-NJ Autonomy Beneficence Confidentiality Nonmaleficence Justice

A nurse is caring for a client who is post-operative and has paralytic ileus. which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

Absent bowel sounds with distention *** Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia B. Place a heating pad at the child's neck for comfort C. Administer analgesics to the child on a routine schedule throughout the day and night D. Provide the child with ice cream when oral intake is initiated

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first? A. Assessment B. Analysis C. Evaluation D. Planning

Assessment

Name the component of the nursing process in which the nurse gathers both subjective and objective information through interview, physical exam, and observation.

Assessment

Select the action the PN participates in with the nursing process. A. Assist the RN with collecting data from the client B. Develop the client care plan using your best judgment C. Perform a comprehensive assessment on the client D. Analyze the objective data from the client

Assist the RN with collecting data from the client

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempt to increase the client's self-motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing areas that might cause client anxiety

Attempt to increase the client's self-motivation

What part of the nervous system controls the heart rate?

Autonomic nervous system

A nurse has performed preoperative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind. I do not want to have this surgery." Which of the following ethical principles is the client using? A. Nonmaleficence B. Autonomy C. Justice D. Fidelity

Autonomy

A nurse is admitting a client who is 162.6cm (64in) tall and weighs 68.2kg (150lb). Using the BMI table, what should the nurse record as the client's BMI?

BMI is 25.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000mL of fluid daily" B. "Increase your intake of refined-fiber foods" C. "Sit on the toilet 30 minutes after eating a meal" D. "Take a laxative every day to maintain regularly"

C. "Sit on the toilet 30 minutes after eating a meal"

A nurse is performing a skin assessment on a patient. What factors is the nurse going to evaluate using inspection? A. color B. temperature C. tugor D. moisture E. Integrity

Color, moisture, integrity

Which of the following are characteristics of the dermis layer of the skin? (Select all that apply) A. Contains blood vessels, hair follicles, and nerve endings B. composed of thick fibrous connective tissue C. secrets melanin D. contains fat storage for energy E. prevents excessive water loss

Contains blood vessels, hair follicles, and nerve endings and composed of thick fibrous connective tissue

A nurse is performing a general assessment on a client's skin. Which of the following observations will require further assessment of the client circulation? A. Skin is warm to touch B. freckles are noted on face C. skin is dry D. cyanosis is noted on fingers

Cyanosis is noted on fingers

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? A. Close the examination room door but do not pull the curtain in the examination room B. Remain in the client's room while the client is getting undressed C. Ask the client if they would like to empty their bladder and bowel before the physical examination begins D. Do not expose any more of the client's body than required at a time

Do not expose any more of the client's body than required at a time

Xerosis

Dry skin

A nurse is preparing to conduct a general survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? A. Have an informal conversation with the client before beginning the observation of the client B. Complete all focused assessments prior to formulating thoughts regarding the client's general health C. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible D. Engage in active listening with the client and allow the client to express concerns early in the assessment process

Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Deduct the client's shoe height from the measurement B. Have the client gently lift their chin and look toward the ceiling C. Ensure the client's feet are in contact with the wall or measuring pole D. Pull up the measuring pole and extend the headpiece after the client steps on the scale

Ensure the client's feet are in contact with the wall or measuring pole

A nurse is performing an assessment on a client and observes A shallow wound on the client's leg. The wound only penetrates the epidermis and there is no bleeding present period which of the following terms correctly describes this wound? A. Fissure B. Wheal C. Erosion D. vesicle

Erosion

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedial pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

Evaluate pedial pulses

What does HIPAA refer to? A. Health information privacy account act B. health insurance paper account act C. health insurance portability and accountability act D. health information portability and accountability act

Health insurance portability and accountability act

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? (Select All That Apply). Height and Weight Past Medical History Current Medication List Behavior and Mood Use of Assistive Devices

Height and Weight, Behavior and Mood, Use of Assistive Devices

Urticaria

Hives, skin rash with red, raised, and itchy bumps

Injuries to the following areas will result in alteration of temperature regulation? (Select All That Apply) A. Pituitary B. Hypothalamus C. Jaw D. Spinal cord

Hypothalamus and spinal cord

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? A. Implementation B. Evaluation C. Analysis D. Planning

Implementation

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspection Percussion Auscultation Palpation

Inspect Auscultation Percussion Palpation *** This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other assessment for an adult client is inspection, palpation, percussion, and auscultation.

A nurse is preparing to perform therapeutic communication with a patient. Which of the following behaviors demonstrate therapeutic communication? (Select All That Apply) A. Ask for explanations B. Give false reassurance C. Keep questions focused and relevant to the context and situation D. Redirect the client as needed E. Clarify to see if the information is accurate F. Give personal opinions G. Give approval and disapproval H. Keep any emotionally charged conversations for last I. Be vigilant throughout the conversation J. Use plural pronouns like "we" K. Use open-ended questions L. Use touch as therapeutic communication

Keep questions focused and relevant to the context and situation Redirect the client as needed Clarify to see if the information is accurate Keep any emotionally charged conversations for last Be vigilant throughout the conversation Use open-ended questions Use touch as therapeutic communication

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

Leukopenia ***Transient leukopenia is an adverse effect of silver sulfadiazine.

A nurse is planning care for a client who has stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include? A. Limit elevation of the head of the bed to 30 degrees or less B. Massage the area every 2 hours C. Reposition the client every 4 hours D. Ensure that the client uses a donut-shaped cushion when sitting in a chair

Limit elevation of the head of the bed to 30 degrees or less *** Raising the head of the bed more than 30º increases the risk for skin damage due to shearing forces. Shearing occurs when the client slides downward in the bed. The outer layer of skin sticks to the bed linens while the deeper skin layers move downward. This results in twisting of blood vessels and can lead to skin damage.

A nurse is caring for a client who has a stage 2 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? Location of the pressure injury Size of the injury in centimeters Depth of the injury in centimeters Color and odor of drainage from the wound The integrity of the skin surrounding the wound

Location of the pressure injury, Size of injury in centimeters, Integrity of the skin surrounding the wound *** Stage 1 pressure injuries present with intact, reddened skin, with no loss of skin or drainage.

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

Montgomery straps ***The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips.

A patient reports pain of the left knee. What acronyms can the nurse use to assess the patients pain?

OLD CARTS onset, location, duration, characteristics, alleviating/aggrevating factors, radiating/relieving factors, treatment/timing, severity PQRST provocation/palliation, quality, region, severity, timing

A nurse is performing a general survey on a client and calculates a BMI of 31 kg/m². The nurse classifies this client in which of the following weight ranges? A. Underweight B. Overweight C. Expected weight D. Obese

Obese *** Underweight less than 18.5 kg/m Healthy weight 18.5 to 24.9 kg/m Overweight 25 to 29.9 kg/m Obesity 30 and above

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select All That Apply) Height Obesity Time of Day Diuretic Medication Smoking

Obesity, Time of Day, Smoking, Diuretic Medication

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? A. Fever 101 B. Pulse rate is tachycardic C. Oxygen saturation 96% on oxygen 2 L/min via nasal cannula D. Blood pressure 108/65 mmHg

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? A. Use the soft end of a cotton swab over the client's abdomen B. Auscultate the tender areas of the client's abdomen through clothing C. Palpate the tender areas of the client's abdomen last D. Use deep palpation when assessing the client's abdomen

Palpate the tender areas of the client's abdomen last

A nurse in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 centimeters in size, elevated, and solid, with very distinct borders. The nurse should document the findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

Papules ***A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.

What part of the nervous system lowers the heart rate?

Parasympathetic nervous system

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select All That Apply). Electrocardiogram monitor Doppler Penlight Tape Measure Tonge Depressor

Penlight, Tape Measure, Tongue Depressor

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? Patches of increased pigmentation on the client's cheeks Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nailbeds Darkly pigmented area across the client's sacral region Light-colored jagged lines

Pinpoint areas of purplish-red coloration across the abdomen and Pale-colored nailbeds,

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Oscillate for the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff 7.6 centimeters or three inches above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is planning to obtain orthostatic blood pressure from a client who has syncope. In what order should the nurse complete the steps? Assist the client to stand and then obtain their blood pressure Keep the cuff in place and assist the client to a seated position Take the client's blood pressure in the supine position Place the client in a supine position and allow them to rest Take the client's blood pressure in a seated position

Place the client in a supine position and allow them to rest Take the client's blood pressure in the supine position Keep the cuff in place and assist the client to a seated position Take the client's blood pressure in a seated position Assist the client to stand and then obtain their blood pressure

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the clients stronger side B. Instruct the client to lean backward from the hips C. Place the wheelchair at a 45° angle to the bed D. Assume a narrow stance with feet 6 inches apart

Place the wheelchair at a 45° angle to the bed ***Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required.

A nurse is preparing to perform mouth care for an unresponsive patient. Which of the following actions should the nurse plan to take? A. Place the client supine B. Keep both side rails up C. Raise the level of the bed D. Inspect the client's mouth using a finger sweep

Raise the level of the bed

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading? A. Hypertension B. Fever C. Recent scan with contrast dye D. Thin, brittle nails

Recent scan with contrast dye *** The dye can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client? A. Axillary B. Temporal C. Tympanic D. Rectal

Rectal

Which of the following is considered an unexpected finding for a 40 year old clients pulse? A. Brisk pulse of +2 B. pulse rate of 95/min C. equal time space between each pulsation D. stronger radial pulse on the left compared to right

Stronger radial pulse on the left compared to right

A nurse is caring for an older client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraint to the side rails B. Perform range of motion exercises to the wrists every three hours C. Remove the restraints one at a time D. Obtain a PRN prescription for the restraints

Remove the restraints one at a time

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? A. Enlist the aid of the client's school-age child to interpret for the nurse and the client B. Ask the client's best friend to interpret for the nurse and client C. Use jokes and laughter to make the client feel more at ease D. Request assistance from an interpreter during the assessment

Request assistance from an interpreter during the assessment

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in a nursing care facilities for early influenza manifestations C. Educating parents of young children about dangers of influenza D. Finding rehabilitation programs for older adults who have complications from influenza

Screening groups of older adults in a nursing care facilities for early influenza manifestations *** Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? A. Tell the client that everything will be fine B. Change the subject while the client is discussing their feelings C. Show interest in the client's feelings by acknowledging that they are upset D. Tell the client that it is wrong to be crying over this situation

Show interest in the client's feelings by acknowledging that they are upset

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client B. Offer to call the clients minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately

Sit and hold the client's hand

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? A. Unexpected sounds made by tapping on the client's skin B. Skin temperature, moisture, or unexpected findings C. Heart sounds, lung sounds, and bowel sounds D. The client's cleanliness and grooming

Skin temperature, moisture, or unexpected findings

What part of the nervous system increases the heart rate?

Sympathetic nervous system

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? A. Bradycardia B. Tachycardia C. Fasciculation D. Tachypnea

Tachycardia

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. the nurse should identify this as which of the following unexpected findings? A. Tachypnea B. Bradypnea C. Apnea D. Hyperventilation

Tachypnea

A nurse is reviewing the vital signs for our client who was admitted with shortness of breath. The nurse notes the client's respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding? A. Hypoventilation B. Tachypnea C. Labored D. Apnea E. Cheyne-strokes respirations

Tachypnea

A nurse on a medical surgical unit is washing her hands prior to assisting with the surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? A. The nurse washes each part of her hands with five strokes B. The nurse washes from the elbows down to the hands C. The nurse washes with her hands held higher than her elbows D. The nurse uses minimal friction when washing her hands

The nurse washes with her hands held higher than her elbows

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure B. The client has been informed about the risks and the benefits of the procedure C. The nurse witnessed the providers explanation of the procedure D. The signature on the preoperative consent form is the clients

The signature on the preoperative consent form is the clients

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

Third-degree frost bite

A nurse is performing a skin assessment on a patient. What factors is the nurse going to evaluate using palpation? A. Color B. Moisture C. Integrity D. Mobility E. Turgor F. Texture G. Temperature

moisture, texture, temperature, mobility, turgor

What is the primary location of diffusion related to respiration?

The alveoli of the lungs

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? (Select All That Apply) "The pain isn't always in the same place." "The pain from my car accident 2 months ago will not go away." "I still have pain since the surgery last month, but it is getting better." "The pain has been off and on for about a year now." "I have had this pain for 9 months."

"The pain has been off and on for about a year now." "I have had this pain for 9 months." "The pain isn't always in the same place."

A nurse observes an assistive personnel preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cough is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

"Using a cuff that is too small will result in an inaccurately high reading."

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing position makes your pain worse, right?"

"What do you think caused the onset of your pain?"

The nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse make? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires everyone to remove their dentures." D. "What worries you about being without your teeth?"

"What worries you about being without your teeth?"

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus

Fasciculation

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? (Select All That Apply) A. Forefinger B. Forehead C. Earlobe D. Thumb E. bridge of nose F. great toe

Forehead, earlobe, bridge of nose

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of PPE should the nurse wear while performing this task? (Select All that Apply) Gown Gloves Goggles N95 Mask Surgical Cap

Gown, Gloves, Goggles

Which of the following is the first action during the physical assessment of the client? A. Asking the client about any allergies B. Auscultating for breath sounds, vowel sounds, and heart sounds C. Palpating any areas of tenderness the client identifies D. Inspecting the client

Inspecting the client

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment? A. Palpation B. Percussion C. Auscultation D. Inspection

Inspection

A nurse is performing a routine assessment on a patient with no known history. List the nursing assessment steps in order of completion as they apply to all systems except the abdomen. A. Inspection B. Percussion C. Auscultation D. Palpation

Inspection Auscultation Palpation Percussion

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

Lower abdomen ***After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse? A. Asking the client to clarify a statement B. Asking the client open-ended questions C. Maintaining an arm's length between self and client D. Stating name and providing credentials upon entering the client's room

Maintaining an arm's length between self and client

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding? A. The client sitting in a relaxed posture B. The client is cooperative in answering the nurse's questions. C. The client tells the nurse that visits from their friends and family make them smile D. The client reports that they feel sad and lonely most of the time

The client reports that they feel sad and lonely most of the time

A nurse is assessing the texture of a client's skin. Which of the following findings require additional investigation? A. Smooth, velvety skin B. moisture in the skin folds C. acne on the back D. oily facial skin

Smooth, velvety skin *** could indicate thyroid disorder

A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEqdL

Sodium 132 mEq/L ***This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.

When conducting a general survey of a client the nurse should assess which three target areas? Gait Skin Turgor Temperature Pupils Respiratory Rate Pain Speech Level of Consciousness

Speech, Gait, Level of Consciousness

A nurse is assessing the client's behavior during the general survey period which of the following does the nurse include in this assessment? (Select All That Apply) A. Clients level of education B. Client speech C. Clients hobbies D. Clients clothing E. Clients occupation

Speech, clothing

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider? A. Yellowed nail color B. White horizontal lines C. Spongy nail base D. Capillary refill time of 2 seconds

Spongy nail base *** The base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider.

You are assessing a client and note a pressure injury on the client's sacrum. The lesion is a deep depression below the level of the skin and subcutaneous fat is visible. What stage of pressure injury would you document for this wound? A. Stage I B. Stage II C. Stage III D. Stage IV

Stage III *** A stage III pressure injury extends completely through the epidermis and into the subcutaneous tissue. Subcutaneous fat may be visible.

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment? A. Tongue Depressor B. Penlight C. Reflex Hammer D. Stethoscope

Stethoscope

Which of the following are tools used with auscultation? (Select All That Apply) A. Dorsal sides of hands B. Pen light C. Tape measure D. Stethoscope E. Doppler

Stethoscope Doppler

A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when I wake up." Which of the following types of data is the nurse documenting? A. Subjective B. Social determinants of health C. Objective D. Olfactory

Subjective

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

Temporal ***The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

What is the acceptable oral temperature range? What is the average temperature?

The average oral temperature range is 96.8-100.4 degrees Fahrenheit. The average oral temperature is 98.6 degrees Fahrenheit.

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate? A. The client has been a chronic smoker for 10 years B. The client takes narcotic pain medication for chronic pain C. The client reports anxiety due to being in the hospital D. The client has a history of anemia

The client takes a narcotic pain medication for chronic pain

The nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? A. The client is feeling better B. The client's abdomen is soft and non-distended C. The client's status is unchanged D. The client appears in pain

The client's abdomen is soft and non-distended

A nurse is providing discharge instructions to a client who is postoperative following a surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of a potential malignancy of a mole? A. Ulceration B. Blanching of the surrounding skin C. Dimpling D. Fading of color

Ulceration ***Ulceration, bleeding, or exudation are indications of a mole's potential malignancy. Increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow-up evaluations and the proper techniques for self-examination of the skin every month.

Which of the following techniques is used with palpation? A. Use short, quick taps with palpation B. use the stethoscope during palpation C. palpate the tender areas before other areas D. use the palmar side of the hand or the pads of the fingers

Use the palmar side of the hand or the pads of the fingers

A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache." Which type of pain should the nurse identify this client is experiencing? A. Visceral B. Somatic C. Neuropathic D. Referred

Visceral

Which of the following actions by the nurse are examples of infection control? (Select All That Apply) A. Washing hands with soap and water for 15 seconds B. wearing artificial nails C. using an alcohol pad to wipe the diaphragm of the stethoscope between clients D. using an alcohol-based rub when hands are not visibly soiled E. wearing sterile gloves when opening gauze dressing packages

Washing hands with soap and water for 15 seconds Using an alcohol pad to wipe the diaphragm of the stethoscope between clients Using an alcohol-based rub when hands are not visibly soiled