Senior Practicum Basic Physical Assessment

A nurse is performing a head and neck assessment on a client who reports fatigue. When palpating lymph nodes, in which location would the nurse palpate the occipital lymph nodes?

Explanation: Lymph nodes are part of the lymphatic system. Lymph nodes vary in size depending upon the body status. There are clusters of head and neck lymph nodes. Using the pads of the fingers, the nurse would palpate the area behind the ears bilaterally to assess the occipital lymph nodes.

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data found in the accident victims would require immediate care?

Severe head injuries Explanation: Clients with severe head injuries are the highest priority because of potential brain damage and spinal cord injury. The other options identified are not life threatening. All are important, but based on ABCs, head injury is first.

The ear canal of an infant or young child:

slants upward. Explanation: The ear canal slants up in a younger child and down in an older child or adult.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate?

Coughing when drinking liquids Explanation: In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a mask-like appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired and coughing would indicated aspiration.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?

Development of an increase in mobility Explanation: This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?

Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse. Explanation: The nurse should wrap an appropriate-size cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can't palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg. Having the client lie down, inflating the cuff to at least 200 mg, and taking blood pressure readings in both of the client's arms aren't appropriate measures.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs. Explanation: The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis Explanation: Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

Posterior tibial Explanation: To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.

Which of the following findings in a client who recently underwent a total hip replacement would require a nurse to take immediate action?

Red painful area on the calf of the affected leg Explanation: Deep vein thrombosis is a complication of total joint replacement and manifestations include a red tender calf. Ecchymosis around the incision site is a normal finding. The client's diaphoresis, fluid volume deficit, and edema in the nonaffected leg should be further assessed; however, the priority is the red tender calf.

Question 3 See full question 18s A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client?

Take her temperature at the same time every morning before getting out of bed. Explanation: The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F (0.28° C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. Explanation: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read the chart.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds. Explanation: Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:

the pulse deficit. Explanation: The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the differential between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he 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, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:

write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Explanation: To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma?

"At first, the stoma may bleed slightly when touched." Explanation: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client?

"Do you wear glasses?" Explanation: The nurse would ask the client whether he wears glasses to evaluate his preoperative cognitive-perceptual pattern. Asking about the client's swallowing pattern would evaluate his nutritional-metabolic pattern. Asking about his need for special equipment to walk would evaluate his activity-exercise pattern. Asking the client about his history of smoking would evaluate his health perception-health management pattern.

Which of the following assessment questions is most likely to yield clinically meaningful data about a female client's sexual identity?

"How do you feel about yourself as a woman?" Explanation: Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?

"Just as I get over a virus, it seems that I get another." Explanation: Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible Explanation: Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status.

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible Explanation: Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status.

A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

38.9° C To convert Fahrenheit degrees to Centigrade, use this formula:

The nurse has received change-of-shift report on the following clients. Who should the nurse plan to assess first?

A client newly admitted after their implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due. Explanation: The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered.

After administering the prescribed medications, which of the following clients requires immediate intervention?

A client taking digoxin who has a morning potassium level of 3.0 mEq/L. Explanation: The client's low potassium level increases the risk for digoxin toxicity and potential dysrhythmias. Digoxin inhibits the action of the sodium-potassium pump that moves sodium and potassium across the cell membrane and slows the electrical impulses through the atrioventricular node. This leads to a rapid reduction of the remainder of potassium ions available for the "pump" action, which can cause a buildup of toxic serum levels of digoxin. Digoxin toxicity can cause many types of cardiac dysrhythmias due to the increased intracellular calcium release and decreased AV conduction time slowing the heart rate. The nurse should notify the healthcare provider about the potassium level to prevent toxicity from occurring. The other clients are experiencing expected effects of the prescribed medication.

A nurse is caring for a Latino client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had his dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

"Tell me what you feeling." Explanation: The nurse should ask the client to tell the nurse what he is feeling. Asking open-ended questions would encourage the client to verbalize pain. Latino men may not demonstrate their feelings or readily discuss their symptoms because they may interpret doing so as being less than manly. Closed-ended questions like "Are you having pain?"; "Do you need pain medication?"; and "Are you feeling alright?" may block communication and the client may not express his feelings.

The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.

- Hello. My name is Nurse Jones from Unit D. - I am notifying you because Bob Smith has become increasingly more short of breath with audible wheezing this afternoon. - Mr. Smith was admitted yesterday with an exacerbation of Asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. - Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. -lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: SBAR communication stands for Situation, Background, Assessment, and Recommendation. First, the nurse must identify his/herself and where he /she is calling from. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

- suicide or self-harm ideation - recent use of substances of abuse - allergic reactions or adverse drug reactions Explanation: When assessing client safety, the nurse assesses suicide thoughts or plan, recent use of illicit drugs (as they may cause impaired judgment or thought processes), and previously experienced allergic reactions and adverse reactions to medications. Note that safety involves many aspects of care. Incentives and diet preferences (allergies would be previously noted) are not directly related to safety, although they may be part of an overall assessment.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would 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 would first find out when the rash began; this can assist with the correct diagnosis. The nurse would 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 would 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 client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. All options must be used.

-Ask the client to urinate. -Auscultate the client's abdomen. -Percuss the client's abdomen. - Perform light palpation. Explanation: The nurse would begin the assessment by having the client empty the bladder first. This allows the nurse to hear abdominal sounds better during auscultation. Because the client is in pain, the nurse would auscultate the abdomen before percussing it. Also, auscultation is usually performed before palpation and percussion since bowel sounds induced by percussion or palpation may mask abdominal bruits or pleural rubs. The nurse would then perform light palpation over the abdomen, leaving the painful area for last.

The client is experiencing parasympathetic responses to pain. What responses should the nurse assess the client for? Select all that apply.

-bradycardia - weakness Explanation: To assess pain properly, the nurse must consider the client's description and the nurse's observations of the client's physical and behavioral responses. Physiologic responses may be sympathetic or parasympathetic in nature. Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis. Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness.

Which client should the nurse assess first?

A client being treated for chronic stable angina who reports a recent increase in chest pain frequency. Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

Which of the following statements heard during shift report identifies an important priority for action?

A postoperative client's pulse has been increasing, and the blood pressure is decreasing. Explanation: This indicates that the status of the client is rapidly changing. When there is an increase in the pulse postoperatively, this could indicate hemorrhage with the body compensating. When the blood pressure is decreasing, this could indicate that the body is now decompensating. Each of the other postoperative situations would represent a normal finding.

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

Assessing the vital signs and oxygen saturation levels Explanation: This correct response is based on principles of ABCs. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the recovery room. Checking the dressing and level of pain are both important, but not the priority.

The nurse notes serous discharge when an abdominal dressing is changed. The nurse would document this drainage as which of the following?

Clear, watery, yellow-tinged drainage Explanation: Serous drainage is clear, watery plasma; sanguineous drainage is fresh, red bleeding; purulent drainage is thick and yellow; and purulent drainage with infection is beige to brown and foul smelling. White with sanguinous drainage and tenacious with yellow drainage are both indicative of an infection. Dark melena and foul smelling is indicative of a gastrointestinal bleed.

To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?

Organs Explanation: The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. The nurse can assess skin turgor, hydration, and temperature by using light touch or light palpation.

The nurse is assessing a client's testes. Which finding indicate the testes are normal?

egg-shaped Explanation: Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the health care provider (HCP).

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest?

thrombophlebitis Explanation: Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

urine output of 90 mL over the past 6 hours Explanation: Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first?

Use a Doppler ultrasound device. Explanation: When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse is not palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the HCP may be necessary if there is a change in the client's condition.

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?" Explanation: An open-ended question (one that cannot be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are closed-ended questions. Having the client describe how the pain medication makes him/her feel does not address the issue of the client's present statement of pain.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

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

The nurse notices redness, swelling, and induration at a surgical wound site. What should the nurses next action be?

Assess the client's temperature. Explanation: Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Explanation: This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addition team but is not medically stable. Sedation is not appropriate at this time.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which order should the nurse anticipate?

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel. Explanation: An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

The nurse is assessing a client's deep tendon reflexes. Which graphic shows assessing the biceps reflex?

Explanation: To test the biceps reflex, the client's elbow is flexed at a 45° angle. The nurse places his/her thumb or index finger over the biceps tendon and strikes the digit with the pointed end of the reflex hammer, watching and feeling for the contraction of the biceps muscle and flexion of the forearm. Option A shows assessment of the patellar reflex. Option B shows assessment of the brachioradialis reflex. Option D shows assessment of the triceps reflex.

The nurse is screening clients for cancer prevention. Which is the recommended screening protocol for colon cancer in asymptomatic clients who have a low-risk profile?

Fecal occult blood testing should be performed annually after age 50 and up to age 75. Explanation: The screening protocol recommended by the American and Canadian Cancer Societies for early detection of cancer in asymptomatic people includes the following: Beginning at age 50, men and women should have fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy every year until age 75 unless determined otherwise by a health care provider (HCP). A diet low in saturated fat and high in fruit and fiber is not a screening protocol but is good dietary advice for all clients.

At 8 a.m.(0800), a nurse assesses a client who's scheduled for surgery at 10 a.m.(1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

Immediately notify the physician of these findings. Explanation: The nurse should notify the physician immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse should then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning whether the physician will proceed with the scheduled surgery.

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which of the following is the best way for the nurse to assess blood pressure?

In the supine, sitting, and standing positions Explanation: By assessing the client's blood pressure in these positions, the nurse can calculate the client's postural pressure, understanding the increase or decrease in blood pressure from a lying to sitting or sitting to standing position. Ambulating the client and taking in the left and then again in the right arm are not accurate assessment tools. Assessing at the beginning and end of the exam is incorrect because this measures a deficit and is not a tool for hypotension.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed?

Level of consciousness, pain level, and wound dressing Explanation: Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

The nurse notices that the client's temperature over the past 24 hours has risen from 98.8°F (37.1°C) to 101.6°F (38.7° C). The nurse completes a head to toe assessment and documents the nurse's note. What would be the nurse's next nursing action?

Notify the healthcare provider Explanation: When the nurse notes a significant rise in temperature to a febrile status, the nurse must first complete a head to toe assessment to obtain all client data and then notify the health care provider. The health care provider may then opt to assess the client or order diagnostic studies to determine a reason for the rise in client temperature. The nurse would pass the data on to the next shift; however, only the health care provider can order diagnostic testing. Early identification of a problem can lead to subsequent treatment. There is no data that the client is short of breath or oxygen compromised that oxygen needs applied. The nurse would not complete a urine culture without a health care provider's order.

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia. The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any increased tenderness on release Explanation: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. She doesn't use light palpation or deep ballottment or maintain fingertip contact with skin to elicit rebound tenderness.

When teaching a group of middle-aged women, what would the nurse include when discussing primary prevention?

Prevention of osteoporosis, the importance of regular breast self-examinations, and Pap smears Explanation: Primary prevention focuses on learning to stay healthy and prevent illness. For middle-aged women, teaching should focus on risk factors for the population. These would include teaching to prevent these problems. Anemia and ulcers are not primary problems of this age group. Fall prevention is more a problem for elderly women.

A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation?

Respect the adolescent's wishes and maintain her confidentiality. Explanation: The nurse should respect the rights of minors who don't want parents informed of medical problems; she shouldn't tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for health care visits involving pregnancy, abortion, or sexually transmitted diseases.

After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed?

Respiratory rate drops from 24 breaths/minute to 16 breaths/minute. Explanation: Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, increased pulse rate, and bubbling breath sounds indicate respiratory secretion accumulation.

Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation?

Urinary output of 20 mL/hr over 2 hours Explanation: Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the physician. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

Shifting dullness over the abdomen Explanation: Shifting dullness over the abdomen indicates ascites, an abnormal finding. Dullness over the liver, bowel sounds occurring every 10 seconds, and vasular sounds over the renal arteries are normal abdominal findings.

A nurse is obtaining the health history of a client whose background differs from her own. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

Tradition and ethnic factors Explanation: Assessing the client's tradition and ethnic factors helps the nurse identify behaviors she should take into account when planning his care. Although the nurse also must consider the client's marital status, financial resources, and community involvement when planning care and rehabilitation, these factors have little relevance when she is formulating culturally acceptable strategies for nursing care.

A client had a total abdominal hysterectomy 10 hours ago. Knowing that sepsis is a potential complication of the surgery, the nurse will monitor for which early assessment change?

Temperature of 101.8° F (38.8° C) Explanation: Sepsis is a potentially life-threatening complication of an infection. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. To be diagnosed with sepsis, a person must exhibit at least two of the following symptoms: fever above 101.3° F (38.5° C) or below 95° F (35° C); heart rate higher than 90 beats/minute; respiratory rate higher than 20 breaths/minute; probable or confirmed infection. The diagnosis will be upgraded to severe sepsis if also exhibiting at least one of the following signs and symptoms, which indicate an organ may be failing: significantly decreased urine output, abrupt change in mental status, decrease in platelet count, difficulty breathing, abnormal heart pumping function, abdominal pain.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation. Explanation: Pulse and respiratory rates normally increase during, and for a short time after, ambulation, especially if it is the first ambulation after 3 days of bed rest. Vital signs should return to baseline within 5-10 minutes after activity. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable. Explanation: When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm and nonmovable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

An African-American (Black) client is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which of the following areas should the nurse check for pallor in the client?

Tongue. Explanation: In the African-American (Black) client, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas have heavy pigmentation.

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

Vesicles Explanation: Vesicles are raised, round, serous-filled lesions that are usually less than 1 cm in diameter. Examples of vesicles include chickenpox (varicella) and shingles (herpes zoster). A pustule is a raised, circumscribed lesion that's usually less than 3/8″ in diameter and contains purulent material that gives it a yellow-white color — for example, acne pustule and impetigo. A plaque is a circumscribed, solid, elevated lesion that's more than 3/8″, in diameter — for example, psoriasis. A papule is a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin — for example, acne papule and lichen planus.

A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would not require further teaching?

Wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference xplanation: When measuring blood pressure, the nurse either removes the client's clothing or moves it above where the cuff will the placed. The nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters of the limb circumference. The nurse chooses bladder size according to the size of the extremity. Using the automatic blood pressure cuff on all clients without cleaning would cause of spread of hospital acquired infections.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. The nurse should first:

call the rapid response team (RRT)/medical emergency team. Explanation: The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Explanation: This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:

changes from the normal expected findings. Explanation: Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.

A client, age 75, is admitted to the hospital. Because of the client's age, the nurse should modify the assessment by:

allowing extra time for the assessment. Explanation: When assessing an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by his first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse uses:

applied anatomy. Explanation: Applied anatomy enables the nurse to base nursing interventions on her knowledge of anatomic findings for nursing care and diagnosis and treatment of medical disorders. She uses developmental anatomy to study structural changes occurring from conception through old age. Regional anatomy refers to the study of limited portions of the body. Descriptive anatomy describes individual body parts in an orderly fashion.

On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n):

diuretic medication. Explanation: The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

elevated temperature Explanation: A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign; therefore, it is a significant sign of infection in a client with immature or depressed WBCs.

The nurse is managing the care of a client diagnosed with Alzheimer's disease, who is being cared for at home. During a conference with the client's family and multidisciplinary team members, the nurse structures care around which priority nursing diagnosis or patient priority?

impaired swallowing Explanation: When working with the client's family and multidisciplinary team, it is most important to select priority nursing diagnosis/patient priority that, many times, includes safety concerns. The nurse is most correct to select impaired swallowing as the highest priority. Impaired swallowing can affect fluid and electrolytes status and nutrition and potentially cause pneumonia. Impaired memory and chronic confusion alone is manageable with appropriate supervision. Impaired verbal communication is an obstacle in expressing thoughts and feelings.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for:

ineffective breathing pattern. Explanation: The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

A nurse must assess skin turgor in an elderly client. When evaluating skin turgor, the nurse should remember that:

inelastic skin turgor is a normal part of aging. Explanation: Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?

institute droplet precautions. Explanation: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

A client's arterial blood gas values are shown. The nurse should monitor the client for:

metabolic acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.

The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to:

observe client performing varied activities of daily living. Explanation: In order to assess the client's ability to perform activities of daily living, it is important for nurses to observe clients actually performing them. This way, nurses can assess any problems occurring with a specific activity. Asking the client what he or she is able to do will not always provide reliable information, and documentation on the chart may not reflect if the client has had help in performing specific tasks. Family members can provide some information but are not trained in how to evaluate the client.

Which sign is an early indication that a client has developed hypocalcemia?

tingling in the fingers Explanation: Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.