Saunders NCLEX questions

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

Identify an object placed in the client's hand.

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6º F (37º C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first?

"When was the last time you had your blood pressure checked?"

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

A blowing or swooshing noise

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Ask the client to shrug the shoulders against the nurse's resistance.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

Pronator Drift

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)?

Pulsation between the umbilicus and the pubis

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

Pleural friction rub

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse should teach the group which point about this procedure?

Do the exam on the same day every month.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

Just under the left clavicle

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

One week after menstruation begins

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes