Passpoint Basic Physical Assessment

A client is determined to be at risk for the development of hypertension and is encouraged by the health care provider to begin using the Dietary Approaches to Stop Hypertension (DASH) eating plan. When reinforcing the information about the plan, what should the nurse be sure to include? Select all that apply.

Eat fruits, vegetables, and whole grains. Nuts such as walnuts, pine nuts, and almonds can help reduce cholesterol. Use fat free or low fat dairy foods such as yogurt and cheese. Explanation: The DASH eating plan encourages the ingestion of foods that are considered heart healthy and include: fruits, vegetables, and whole grains. Foods to avoid are high in saturated fats, trans fats, added sugars, alcohol, and sodium. Nuts such as walnuts, pine nuts, and almonds have good oils that can help reduce cholesterol. Fat free or low fat dairy foods such as yogurt and cheese provide needed calcium.

The nurse is caring for a client admitted with a fever, prolonged vomiting, and diarrhea for the last 2 days. The health care provider has diagnosed food poisoning. When assisting with the plan of care, what interventions does the nurse anticipate providing?

Maintaining hydration with intravenous (IV) fluids Explanation: Maintaining hydration with IV fluids may prevent acute kidney injury from rapid dehydration. Administration of antibiotics will not be effective if the causative agent is a viral infection and the overuse of antibiotics can also cause bacterial resistance. The use of certain antibiotics can also cause Clostridium difficile, which can make the diarrhea worse. Fluids by mouth would be discouraged while the client is still having vomiting and diarrhea. Cleansing enemas would be contraindicated in this situation and do not eliminate bacteria from the colon.

A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. Which task should she assign to another LPN?

Performing dressing changes Explanation: Nursing assistants can't perform dressing changes; this measure must be performed by a licensed nurse. Nursing assistants, according to their job description, can assist with meals, obtain vital signs, and assist with bathing clients.

A nurse is caring for a client who has returned from esophagogastroduodenoscopy (EGD). Prior to offering oral fluids, what is a priority action by the nurse?

Check the gag reflex. Explanation: Before giving oral fluids, it is essential that the client has recovered sufficiently to be able to swallow. Monitoring urinary output, pain level, and positioning is completed postoperatively but does not impact the ability to offer oral fluids.

A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform?

Check the glucose level. Explanation: Blood glucose level should be immediately measured when a client is unresponsive for no apparent reason or if hypoglycemia is suspected. This client is NPO and at risk for hypoglycemia. When blood glucose levels fall below 40 to 50 mg/dL, cerebral function declines rapidly. An ECG or EEG may be performed but would not be the priority in this situation. There is no indication that the client has received a narcotic, so the administration of a narcotic antagonist would be unnecessary.

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.)(0800), 60 ml (9 a.m.) (0900). Based on these amounts, what should the nurse do?

Continue to monitor and record hourly urine output. Explanation: Normal urine output for an adult is approximately 1,500 ml/24 hours, which averages to about 60 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. The nurse should report urine output less than 30 ml/hour, which may indicate dehydration or altered renal function.

While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate:

Cerebrospinal fluid leak. Explanation: Clear, thin nasal drainage may indicate a cerebrospinal fluid leak. The nurse should immediately report this finding to the physician. Clear, thin nasal discharge doesn't indicate infection, epistaxis, or the presence of a foreign body.

The nurse is caring for a client who was admitted with a stroke. The client has left-sided paralysis. How should the nurse document this finding?

Hemiplegia Explanation: Hemiplegia refers to paralysis of one side of the body. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?

In a circle, from the center outward Explanation: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward to prevent contamination of the drain insertion site. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound, and wipes from top to bottom when cleaning a vertical incision. Cleaning from the outside to the inside in a circular motion would contaminate the drain insertion site.

The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation?

"S1 is loudest at the apex, and S2 is loudest at the base." Explanation: The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection?

Allowing extra time for this task Explanation: When collecting data on an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, should address the client respectfully rather than by his or her first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

A nurse is caring for a client with renal failure requiring peritoneal dialysis. The nurse does not feel comfortable performing the procedure. Which actions would be the most appropriate for the nurse to take? Select all that apply.

Ask the supervising nurse for assistance in using the equipment. Talk with the charge nurse about not feeling comfortable with the procedure. Explanation: When unsure about a procedure or piece of equipment, the nurse should tell the supervising nurse about the discomfort and ask for assistance with the task. If appropriate training or assistance is not available, the nurse should ask for a different assignment. The procedure should not be postponed for the shift because this could lead to serious complications. Asking the client how to use the equipment is inappropriate. The nurse should never perform a procedure that the nurse does not feel prepared to perform.

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk Explanation: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

A nurse is reviewing a client's chart. Which documentation does the nurse expect to find to indicate that the client's reaction is a normal response to a corneal sensitivity test?

Blinking Explanation: The normal response to a corneal sensitivity test is blinking. Sudden onset of seeing spots or flashing lights may indicate retinal detachment. Pupil dilation occurs when the eye is exposed to darkness. Pupil contraction normally occurs when the pupil is exposed to direct light.

Question 1 See full question22sReport this Question The nurse plans to obtain client information from a primary source. Which does the nurse identify as a primary information source and collects data from?

The client Explanation: The client is the only primary information source. Family members, the physician, and previous medical records are examples of secondary information sources.

The nurse is caring for a client with a Jackson-Pratt drain. While emptying the drain, the nurse is splashed with blood. Which of the following actions should the nurse take?

wash affected area with soap and water Explanation: Washing the affected skin with water and soap ensures removal of the blood by rubbing the skin. Alcohol is not effective against virus and fungi. Paper towel alone, especially a dry paper towel, will not completely eliminate the blood.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash? Select all that apply.

"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" Explanation: The nurse should first find out when the rash began; this can assist with the correct diagnosis. The nurse should also ask about allergies; rashes can occur when a person changes medications, eats new foods, or contacts pollen. It is also important to find out how the client has been treating the rash; some topical ointments or oral medications may worsen it. The nurse should ask about recent travel; exposure to foreign foods and environments can cause a rash. The client's age and smoking and drinking habits would not provide further insight into the rash or its cause.

A licensed practical nurse (LPN) who typically works on a medical-surgical unit is being cross-trained to work with postpartum clients. The nurse-manager is busy with a client who is giving birth and assigns the LPN to stock client rooms. Entering a client's room, the LPN notices that the client looks pale and shaky. Which action should the LPN take?

Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager. Explanation: Licensed professionals are always held accountable for practicing according to the level of education they have attained. Therefore, even though the LPN has been assigned to do work usually done by a nursing assistant, the LPN is held accountable within the standards of practice for an LPN. It is within the scope of practice for an LPN to collect vital signs data, complete a cursory examination of the client's fundus and flow, and report findings to the nurse-manager. The client should not be left alone until the LPN establishes through data collection that doing so is safe for the client. If the client is unstable, the LPN should stay with the client and call for help.

Which data collection finding by the nurse contraindicates the application of an aquathermic heating pad?

Active bleeding Explanation: Heat application increases blood flow and therefore is contraindicated in a client with active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A nurse participating in planning care for a client who is in labor expects to monitor the client's blood pressure frequently. Why is this action important?

Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.

The health care team is performing cardiac compressions on an adult client. To assess the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR), the nurse palpates which pulse site on this client?

Carotid Explanation: During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) no longer are palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client?

Carotid Explanation: During rapid data collection, the nurse's first priority is to check the client's vital functions by checking his or her airway, breathing, and circulation. To check a client's circulation, the nurse checks the client's skin color, temperature, mental status, and, most importantly, his or her pulse. The nurse should use the carotid artery to check a client's pulse. In a client with a circulatory problem or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid data collection of an infant. The femoral pulse isn't easily accessible.

The unlicensed assistive personnel (UAP) reports to the nurse that a client became short of breath while being bathed but is breathing better now. Which action should the nurse take first?

Check the client and gather subjective and objective data related to shortness of breath. Explanation: The nurse must assess the client to determine what caused the episode and obtain a pulse oximetry reading, if indicated. Instructing the UAP to observe the client for further shortness of breath would be appropriate after the nurse has checked the client. It wouldn't be necessary at this time to call the health care provider about the client's episode of shortness of breath since the client's breathing has improved, but the health care provider should be informed in a timely manner, and this should be documented. After checking the client, the nurse may ask the UAP to complete the bath after allowing the client to rest.

A client on bedrest with an indwelling urinary catheter informs the nurse of having discomfort in the lower abdomen. What is the first action by the nurse?

Check to see if the catheter is kinked Explanation: The urinary catheter should be checked for kinks. There is no indication that the catheter should be removed and reinserted; this also increases the client's risk of infection. Irrigation of the catheter is not routine care and is not indicated. There is not enough data to indicate that the client is having a urinary tract infection.

The nurse is caring for a client with stomatitis. To make eating less painful, which foods should the nurse suggest?

Soft, bland foods Explanation: The nurse should suggest that the client with stomatitis eat soft, bland foods, such as applesauce, which are less irritating to sore mouth tissue. Hot and dry foods may irritate a sore mouth. Liquid foods are less satisfying and aren't necessary for a client with stomatitis.

A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next?

Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth. Explanation: The nurse should obtain the specimen by swabbing the tonsillar areas, including the inflamed and purulent sites, from side to side. The nurse should avoid touching the tongue, cheeks, and teeth with the swab to prevent contaminating the specimen.

A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention? You Selected:

Teaching the client how to deep-breathe and cough Explanation: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition but doesn't address poor coughing. Improving airway clearance is too vague. Suctioning isn't indicated unless other measures fail to clear the airway.

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:

Withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, food and fluid should be withheld until the gag reflex returns. There is no indication for oral airway placement. The client should be in the upright position, and inserting an NG tube is unnecessary.

The licensed practical nurse (LPN) is caring for a group of clients on a medical-surgical floor. Which client should the nurse attend to first?

a client whose lower leg is red and swollen Explanation: The LPN should first attend to the client whose lower leg is red and swollen. This client may have deep vein thrombosis caused by immobility, which should be investigated further. An apical pulse rate of 80 beats/minute is within normal limits. The LPN should address the clients' concerns about going home and receiving the breakfast tray; however, those concerns don't take priority.

A 2-year-old child is brought to the ambulatory care clinic by the parent for a routine well-child visit. What musculoskeletal finding would indicate to the nurse the need for further investigation?

asymmetric or unilateral bowleg Explanation: Asymmetry of body parts is generally a clue to a problem. Unilateral bowleg that is present past the age of 2 may represent a pathologic condition. A broad-based gait and lordosis are normal findings in a toddler. Knock-knee is normally present in most children ages 2 to 7 years.

A client hasn't voided since before surgery, which took place 8 hours ago. When collecting data on the client, the nurse should:

palpate the bladder above the symphysis pubis. Explanation: Eight hours is a long time not to have voided. Typically, the kidneys produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder should be full of urine and palpable above the symphysis pubis. If the bladder isn't full after 8 hours, the client's kidneys may be malfunctioning or the client may be dehydrated.

A nurse places a client who is suspected of having tuberculosis in isolation. Which part of the chain of infection do isolation techniques interfere with?

transmission mode Explanation: Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques do not affect the agent, host, or portal of entry.