Basic Physical Assessment
To evaluate a client's cerebellar function, a nurse should ask "Do you have any difficulty speaking?" "Do you have any trouble swallowing food or fluids?" "Have you noticed any changes in your muscle strength?" "Do you have any problems with balance?"
"Do you have any problems with balance?" Explanation: To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help the nurse evaluate the client's motor system.
The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and oxygen saturation (SpO2) is 90% on a 50% partial rebreather mask. What should the nurse do next? Ventilate the client with a bag-mask device. Begin chest compressions. Call the rapid response team. Remove the family from the room.
Call the rapid response team. Explanation: The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided.
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should perform which action first? Inquire about the health of siblings at home. Institute droplet precautions. Ask the parent about medication allergies. Obtain the child's vital signs.
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 for 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
Why should the nurse avoid palpating both carotid arteries at one time? The nurse can't assess the pulse accurately unless the arteries are palpated one at a time. Palpating both arteries at one time may cause transient hypertension. Palpating both arteries at one time may cause severe bradycardia. Palpating both arteries at one time may cause severe tachycardia.
Palpating both arteries at one time may cause severe bradycardia. Explanation: 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 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. The client maintains skin integrity. The client verbalizes a manageable level of discomfort. The client expresses positive feelings about self-image.
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.
The nurse is not able to palpate the left pedal pulses of a client with peripheral artery disease. What should the nurse do first? Call the health care provider (HCP). Use a Doppler ultrasound device. Auscultate the pulses with a stethoscope. Inspect the lower left extremity.
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.
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 the client has no active gag reflex. What is the next action by the nurse? Introduce a nasogastric (NG) tube. Insert an oral airway. Withhold food and fluids. Position the client on the side.
Withhold food and fluids. Explanation: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse would withhold food and fluid until the client's gag reflex returns. The client would be placed in an upright position. There is no indication that oral airway placement would be appropriate or that an NG tube is needed
The nurse is performing a digital rectal examination. Which finding is a key sign of prostate cancer? a boggy, tender prostate abdominal pain a nonindurated prostate a hard prostate, localized or diffuse
a hard prostate, localized or diffuse Explanation: On digital rectal examination, key signs of prostate cancer are a hard prostate, induration of the prostate, and an irregular, hard nodule. Accompanying symptoms of prostate cancer can include constipation, weight loss, and lymphadenopathy. Abdominal pain usually does not accompany prostate cancer. A boggy, tender prostate is found with infection (e.g., acute or chronic prostatitis).
Which client should the nurse assess first? a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker
a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.
Which finding will the nurse assess in a client diagnosed with peritonitis? abdominal wall rigidity Battle's sign positive Cullen's sign absence of bowel sounds
abdominal wall rigidity Explanation: Abdominal wall rigidity is a common manifestation of peritonitis. Bowel sounds may or may not be present in peritonitis. A positive Cullen's sign is a manifestation of acute pancreatitis, and Battle's sign is a manifestation of skull fractures.
The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse? palpation for rebound tenderness over the lower abdominal area review of the abdominal X-ray report administration of pain medications auscultation of all four quadrants using a stethoscope
auscultation of all four quadrants using a stethoscope Explanation: The order of abdominal assessment includes observation, auscultation, percussion, and palpation. An assessment would be completed prior to reviewing the diagnostic report. The nurse would assess the client prior to administering pain medication.
The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should: ask the client to drink a glass of warm water prior to auscultation. expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. listen for 2 minutes in each area of the abdomen. use the bell of the stethoscope.
expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Explanation: Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 5 minutes, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds.
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 which nursing problem? ineffective breathing pattern alteration in level of consciousness alteration in urinary elimination altered cardiac functioning
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 client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation? metabolic alkalosis respiratory alkalosis respiratory acidosis metabolic acidosis
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.
A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? pulse pressure pulse rhythm pulse deficit pulsus regularity
pulse deficit Explanation: The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the difference 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.
When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? vesicle papule pustule macule
vesicle Explanation: A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.
Upon assessment, the nurse identifies bronchovesicular sounds over the right peripheral lung field. What question should the nurse ask the client next? "Did you receive a breathing treatment today?" "Can you please cough?" "Do you feel pain when taking a deep breath?" "Do you have any shortness of breath?"
"Do you feel pain when taking a deep breath?" Explanation: Bronchovesicular breath sounds are tubular sounds (not as loud as bronchial sounds) and best heard posteriorly between the scapulae. If bronchovesicular sounds are heard in the peripheral lung field, it indicates pneumonia or tissue consolidation. If the client has pain on inspiration, pneumonia should be suspected. Asking the client to cough, if there is shortness of breath, or if a breathing treatment has been given will not provide the nurse with information regarding the cause of the bronchovesicular breath sounds.
Which assessment question is most likely to yield clinically meaningful data about a female client's sexual identity? "How do you feel about yourself as a woman?" "Do you find that your health allows you to enjoy a meaningful sex life?" "Have you ever had any sexually transmitted diseases in the past?" "Are you satisfied with the quality of your relationships right now?"
"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.
Which factors are major components of a client's general background history? bowel habits and allergies urine output and allergies allergies and socioeconomic status gastric reflex and the client's age
allergies and socioeconomic status Explanation: General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.
The nurse is assessing a client who has had hoarseness for more than 2 weeks. What action should the nurse take? Refer the client to a health care provider for a prescription for an antibiotic. Instruct the client to gargle with salt water at home. Assess the client for dysphagia. Instruct the client to take a throat analgesic.
Assess the client for dysphagia. Explanation: Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness were accompanied by a sore throat.
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? Metabolic rate, orientation, and presence of reflexes Emotional status, response to anesthesia, and social support systems Skin color, warmth of extremities, and mental status assessment Level of consciousness, pain level, and wound dressing
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.
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? One breast is larger than the other. The lump is round and movable. Nipple retractions are noted. The lump is firm and non-movable.
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 non-movable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.
When palpating the bladder of an adult client, a nurse would identify which finding as normal? a hard, rough bladder a palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis a soft, smooth bladder a nonpalpable bladder
a nonpalpable bladder Explanation: An adult's bladder may not be palpable. An adult's bladder that is palpable is usually firm, smooth, and located 1″ to 2″ (2.5 to 5 cm) above the symphysis pubis
A client is receiving chemotherapy through a central venous catheter into the right subclavian vein. The client is reporting pain in the chest and shoulder. The nurse observes that the client is dyspneic and cyanotic and the blood pressure has dropped to 86/48 mm Hg. The client's pulse is weak and rapid, and the client has a fever. What complication would the nurse suspect? infiltration at the site of insertion circulatory overload due to infusion of fluid systemic infection air embolism
systemic infection Explanation: Infection should be suspected because of the signs and symptoms of inflammation. There is no indication of excess fluid, so circulatory overload is not the issue. Nor are there signs and symptoms of an air embolus or infiltration at the intravenous site.
A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider? lower peripheral pulses +1 bilaterally nails are thickened, brittle, and yellow urine output of 600mL/24 hours increased sensitivity to glare
urine output of 600mL/24 hours Explanation: Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? confusion when listening to explanations of procedures urine output of 90 mL over the past 6 hours polydipsia a core body temperature of 97.9° F (36.6° C)
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.
An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? increased immunocompetence increased scarring decreased healing decreased melanin and melanocytes
decreased healing Explanation: Normal aging consists of a decreased proliferative capacity of the skin. Decreased collagen slows capillary growth, impairs phagocytosis among older clients, and results in slow healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes give color to the skin and hair but are increased with aging. There is a decrease in the immunocompetence of the aging client.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? every 5 minutes every 10 minutes every 20 minutes every 15 minutes
every 15 minutes Explanation: To prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.
A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? in the supine, sitting, and standing positions assessing at the beginning and the end of the examination taking blood pressure on the left arm and again in 5 minutes on the right arm ambulating the client around the room and then assessing 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.
he nurse has just received report on four clients. Which client should be seen first? a client with diabetes whose fingerstick blood glucose was 90 mg/dL 1 hour ago a client diagnosed with asthma who just received respiratory therapy treatment a client feeling sweaty and requesting antacid for stomach upset a client who had a cardiac catheterization 8 hours ago whose vital signs have been stable for the last 2 hours
a client feeling sweaty and requesting antacid for stomach upset Explanation: Signs of indigestion and sweating can be signs of impending myocardial infarction that should be carefully assessed by the nurse. The client who had the cardiac catheterization has stable vital signs and should be reassessed after assessing the client with a potential impending myocardial infarction. The client who had respiratory therapy does not require immediate attention. The client with diabetes has a normal finger stick glucose level and does not require immediate attention.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? changes from the normally expected findings skin turgor similarities from one side to the other appearance of age-related wrinkles
changes from the normally expected findings Explanation: Noting changes from the normally 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 nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? referring a client who reports joint pain to a healthcare provider specialist teaching a client who has asthma how to use a rescue inhaler administering digoxin to a client who has heart failure obtaining a rubella titer on a woman who is planning to start a family
obtaining a rubella titer on a woman who is planning to start a family Explanation: Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). What should the nurse do next? Encourage the client to eat at least half of a banana per day. Restrict the client's sodium intake. Encourage the client to increase fluid intake. Withhold the next dose of antihypertensive medication.
Encourage the client to increase fluid intake. Explanation: The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which would be the best response by the nurse? "You have no need to worry. Your blood pressure is probably elevated because you are in the physician's office." "We will need to reevaluate the blood pressure because your age places you at a high risk for hypertension." "You will need to have your blood pressure reassessed before a diagnosis can be made." "It's fortunate that you came into the clinic today and this was caught this during your routine examination."
"You will need to have your blood pressure reassessed before a diagnosis can be made." Explanation: Hypertension is confirmed by at least two measurements greater than 129/80 mm Hg and taken on two separate occasions. The nurse should provide factual information to the client, not provide false hope.
The nurse has received the change-of-shift report on the clients. Who should the nurse assess first? a client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70 a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due a client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am (1000) for an ablation a client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating
a client newly admitted after the 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.
A client asks the nurse why a prostate-specific antigen (PSA) level is determined before a digital rectal examination. What should the nurse tell the client? "It is easier for the client." "A prostate examination can possibly increase the PSA." "If the PSA is normal, the client will not have to undergo the rectal examination." "A prostate examination can possibly decrease the PSA."
"A prostate examination can possibly increase the PSA." Explanation: Manipulation of the prostate during a digital rectal examination may falsely increase PSA levels. The PSA determination and the digital rectal examination are no longer recommended as screening tools for prostate cancer. Prostate cancer is the most common cancer in men and the second leading cause of death from cancer among men in the United States and Canada. Its incidence increases sharply with age, and the disease is predominant in men in their 60s and 70s
Four people who have been injured in a car crash are admitted to the emergency department. According to the emergency severity index (ESI), in which order from first to last should the clients be seen by a health care provider (HCP)? All options must be used. 1-an older adult with normal vital signs, but is confused 2-an adult with bleeding through a pressure dressing from a laceration in the leg 3-a child with lacerations on the arms and legs 4-an adult with a history of asthma and respirations of 22 breaths per minute
-an adult with bleeding through a pressure dressing from a laceration in the leg -an adult with a history of asthma and respirations of 22 breaths per minute -a child with lacerations on the arms and legs -an older adult with normal vital signs, but is confused Explanation: Using the ESI, the nurse should triage the clients to be seen by an HCP as follows: the adult with severe bleeding through a pressure dressing is categorized as level 1, life-threatening, and should be seen first; the adult with asthma and increased respirations is in the emergency category, and should be seen next; the child with lacerations is categorized as less urgent and can be seen next; the older adult has vital signs within normal range and is assessed as being non-urgent and can be seen last.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb to the hips. What should the nurse do next? Select all that apply. Place respiratory resuscitation equipment in the client's room. Have the client perform ankle pumps. Check for advancing levels of paresthesia. Notify the health care provider (HCP) of the change. Notify the family of the change.
Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. Explanation: A client who has been admitted for numbness and tingling in the lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The HCP must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.
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. Document history of the symptoms. Insert an NG tube and connect to suction. Assess bowel sounds and abdominal tenderness.
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.
While listening to a client's chest, the nurse notes a grating sound on inspiration and expiration. When communicating with the health care provider, what would the nurse request? nebulizer treatments chest X-ray arterial blood gas narcotic pain medications
chest X-ray Explanation: A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound. The rub is never a normal finding; it occurs with pneumonia, pulmonary embolism, pleural effusion, or pleurisy. Because these conditions could be severe, a chest X-ray would better diagnose the condition. None of the other options would diagnose the cause.
A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate: metabolic alkalosis. respiratory acidosis. metabolic acidosis. respiratory alkalosis.
respiratory acidosis. Explanation: Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.
Which sign is an early indication that a client has developed hypocalcemia? depressed reflexes tingling in the fingers memory changes ventricular dysrhythmias
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.
A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should palpate both carotid arteries firmly first, then auscultate to compare. palpate the radial artery during auscultation. use the bell of the stethoscope. have the client inhale and exhale though the mouth during auscultation.
use the bell of the stethoscope. Explanation: With the client holding their breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits. Having the client inhale would interfere with the nurse's ability to detect sound. Palpating the radial artery wouldn't yield significant information and could interfere with the nurse's ability to listen without interruptions or distractions. Palpating both carotid arteries simultaneously would stop blood flow to the brain.
A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? plaque papules vesicles pustules
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 caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? "Do you need pain medication?" "Are you feeling all right?" "Are you having pain in your leg?" "Tell me what you are feeling."
"Tell me what you are feeling." Explanation: The nurse should ask the client to tell the nurse what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions like "Are you having pain?", "Do you need pain medication?", and "Are you feeling all right?" may block communication.
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?" "Are you having pain?"
"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 them feel does not address the issue of the client's present statement of pain.
After administering prescribed medications to clients, which client requires immediate intervention? a client taking captopril who has a nonproductive cough a client with a nitroglycerine patch who has a headache a client taking atenolol who has a heart rate of 58 a client taking digoxin who has a morning potassium level of 3.0 mEq/L
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.
After administering prescribed medications to clients, which client requires immediate intervention? a client with a nitroglycerine patch who has a headache a client taking captopril who has a nonproductive cough a client taking digoxin who has a morning potassium level of 3.0 mEq/L a client taking atenolol who has a heart rate of 58
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.
The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action? Clean with antiseptic material and re-dress the site. Assess the client's temperature. Evaluate the client's white blood cell count. Notify the health care provider.
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.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube? Copious fluid leakage from the stoma Moist bright red stoma with a scabbed area on one side Raised red papules around the stoma Dark pink stoma without drainage
Dark pink stoma without drainage Explanation: A normal stoma should appear dark pink to red in color and should have no drainage or scant crusty drainage around the feeding tube. Copious fluid leakage from the stoma is not normal, and may indicate the stoma has enlarged, the tube is cracked or dislodged, the balloon has deflated, or another complication. Raised red papules around the stoma can indicate a yeast or candida infection. Yeast grows in moist areas, such as under the external part of the gastric or jejunostomy tube. A bright red stoma could indicate infection, and a scabbed area on one side indicates tissue damage and is not a normal assessment finding.
On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription? additional fluid intake diuretic medication increased oxygen liter flow rate antihypertensive medication
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.
What is an expected assessment finding when caring for a client with a percutaneous feeding tube? Moist bright red stoma with a scabbed area on one side Raised red papules around the stoma Dark pink stoma without drainage Copious fluid leakage from the stoma
Dark pink stoma without drainage Explanation: A normal stoma should appear dark pink to red in color and should have no drainage or scant crusty drainage around the feeding tube. Copious fluid leakage from the stoma is not normal, and may indicate the stoma has enlarged, the tube is cracked or dislodged, the balloon has deflated, or another complication. Raised red papules around the stoma can indicate a yeast or candida infection. Yeast grows in moist areas, such as under the external part of the gastric or jejunostomy tube. A bright red stoma could indicate infection, and a scabbed area on one side indicates tissue damage and is not a normal assessment finding.
For which client is the nursing assessment of pain most likely to result in undertreatment? a Asian American client who requests medication for pain following abdominal surgery an older adult who grimaces and states no pain after a gastrostomy tube placement a young adult who vomits and keeps eyes closed during a migraine headache attack a black adult who has a client-controlled analgesic I.V. following cardiac surgery
an older adult who grimaces and states no pain after a gastrostomy tube placement Explanation: Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled
A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications? "I haven't been able to eat anything solid for the past 2 days." "I've never had surgery before." "I've cut my smoking down from two packs to one pack per day." "I had an operation 2 years ago, and I don't want to have another one."
"I've cut my smoking down from two packs to one pack per day." Explanation: Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery. Lack of solid foods for 2 days before surgery, no history of previous surgery, or anxiety about surgery wouldn't increase the risk of postoperative complications.
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 expresses positive feelings about self-image. The client exhibits signs of adequate GI perfusion with normal bowel sounds. The client verbalizes a manageable level of discomfort. The client maintains skin integrity.
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 client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate? prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin split product values cardiac monitoring, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel EEG (electroencephalogram), alkaline phosphatase and aspartate aminotransferase levels, and basic serum metabolic panel
ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Explanation: Diagnostic testing is one source of information leading to a medical diagnosis. It is correct to anticipate cardiac and gastrointestinal studies due to the client's signs and symptoms. 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 emergency department (ED) nurse should assess which client first? a 72-year-old who fell from the porch and has a painful probable fracture of the right arm a 3-day-old who the parents identify as having yellow discoloration on the chest and abdomen a 12-year-old who has a bleeding laceration on the knee possibly requiring stitches a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain
a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain Explanation: When the nurse is presented a choice between who to see first, safety and seriousness of the condition are considerations. The individual from the motorcycle accident is stating pain that could indicate internal injuries, a serious complication. This individual would be assessed by the nurse first. Through delegation and prioritization of the remaining clients, the others will have their needs met by the registered nurse and members of the health care team. The nurse identifies physiological jaundice in the 3-day old neonate. Diagnostic lab work will be completed and parental teaching on increasing feedings. A simple dressing on the bleeding laceration could be placed by a licensed practical/vocational nurse or nursing assistant until seen by the healthcare provider. The fractured arm will be examined and x-rayed confirming the fracture.
