Exam 1 Practice Questions P2
While assessing an older adult client's respirations, the nurse can anticipate that the respiratory pattern may exhibit a shorter inspiratory phase. longer inspiratory phase. shorter expiratory phase. longer expiratory phase.
shorter inspiratory phase. Explanation: In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging.
A client's spouse reports to the nurse that the client sometimes stops breathing during sleep and asks if this is serious. What is the best response by the nurse? "Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." "Everyone experiences periods of apnea when they are in deep REM sleep." "Your spouse is suffering from a normal condition of aging known as sleep apnea." "Your spouse has sleep apnea, which can cause problems with blood pressure."
"Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." Explanation: Individuals with sleep apnea are at risk for hypertension, heart attack, brain attack (stroke), and motor vehicle accidents. While the response where the nurse states sleep apnea causes problems with blood pressure is correct, it is not specific in what the problem is: hypertension. As we age, the risk for sleep apnea increases, but sleep apnea is not a normal part of aging and the response does not answer the spouse's question. Sleep apnea is not an expected finding of REM sleep.
A mother brings her 5-year-old son who is of African descent to the clinic. The mother is concerned about recent changes in her child's hair color from black to a copper-red. What is the best response by the nurse? "This is normal in young children of African descent." "Your son may have a hypothyroid." "This could be a sign of malnutrition." "Your son may have folliculitis."
"This could be a sign of malnutrition." Explanation: Copper-red hair in children of African descent may be a sign of severe protein malnutrition. Changes in hair color from black to copper-red hair in children of African descent is not a normal finding. Hypothyroidism causes patchy, thin hair, not a change in hair color. Folliculitis is an infection of the follicle causing pustules and erythema.
x What is the expected respiratory rate (in breaths per minute) when inspecting the thorax of an adult client? 10-16 12-18 14-20 None of the above
14-20 Explanation: Adults normally take 14 to 20 breaths per minute in a quiet regular pattern.
As a nursing student you learn that the normal range for an adult pulse is what? 80-120 bpm 70-110 bpm 60-100 bpm 50-90 bpm
60-100 bpm Explanation: If the rhythm is regular and the rate seems normal, count the rate for 30 seconds and multiply by 2. If the rate is unusually fast or slow, however, count it for 60 seconds. The range of normal is 60-100 beats per minute.
While interviewing a new client, you notice that he is mirroring your position. What can this signify? An increasing sense of connectedness A desire to be on an equal power level A desire for increased rapport The client does not take you seriously
An increasing sense of connectedness Explanation: Matching your position to the client's can signify increased rapport, just as mirroring your position can signify the client's increasing sense of connectedness.
One technique of therapeutic communication is silence. What does silence allow the client to do? Learn to trust the nurse Change topics if he or she wants Communicate concerns nonverbally Decide how much information to disclose
Decide how much information to disclose Explanation: Silence may give clients a chance to decide how much information to disclose.
A female client visits the health care clinic with reports of hair falling out in clumps and a butterfly rash on her face. She begins to cry and states: "I am so ugly with this rash!" Which nursing diagnoses can the nurse confirm with this data? Select all that apply. Disturbed Body Image Ineffective Individual Coping Anxiety Impaired Skin Integrity Risk for Infection
Disturbed Body Image Ineffective Individual Coping Anxiety Explanation: This client expresses concern about her appearance and displays emotional reaction to the rash. These are defining characteristics that can confirm the nursing diagnoses of Disturbed Body Image, Ineffective Individual Coping, and Anxiety. There is no evidence of Impaired Skin Integrity or Risk for Infection.
A client comes in with shortness of breath and a productive cough. The client's body has black henna skin decorations in many areas including the fingertips. The nurse wants to assess the client's oxygen saturation. Where would the nurse most likely get an accurate reading of oxygen saturation? Ear Middle finger Great toe Bridge of the nose
Ear Explanation: Black henna causes major errors in oxygen saturation readings, while red henna does not. Use of ear oximetry is recommended for clients with black henna applied to their fingertips. The nurse would not measure oxygen saturation from the middle finger if skin decorations were on the fingertips; generally, the nurse does not measure oxygen saturation on the great toe of an adult and does not measure oxygen saturation on the bridge of the nose.
When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding? Enlarged pharyngeal tonsils Enlarged palatine tonsils Enlarged adenoids Enlarged lingual tonsils
Enlarged palatine tonsils Explanation: The palatine tonsils are located on either side of the oropharynx. The pharyngeal tonsils or adenoids are located high in the nasopharynx. The lingual tonsils lie at the base of the tongue.
Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents? Noting a widened pulse pressure Asking whether the client is light-headed Assessing for a rise in blood pressure when standing Evaluating orthostatic hypotension
Evaluating orthostatic hypotension Explanation: For a client taking antihypertensive agents, the nurse should assess for possible orthostatic hypotension, which could increase the client's risk for falls. The blood pressure would fall with a change in position from lying to sitting or standing. A widening pulse pressure may be seen with aging.
Your lab instructor explains that physical examination relies on what cardinal assessment technique? Assessment Percussion Organization Communication
Percussion Explanation: Note that the physical examination relies on four classic techniques: inspection, palpation, percussion, and auscultation.
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? PIE SBAR DAR SOAP
SBAR Explanation: Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes.
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? Papule Vesicle Bulla Crust
Vesicle Explanation: Herpes zoster (shingles) is characterized by grouped vesicular skin eruptions along a cutaneous sensory nerve line. The vesicles typically are less than 0.5 cm. Elevated nevi or warts would be noted as papules. Bulla would be vesicles greater than 0.5 cm. Crust is a dried residue of serum, blood, or pus on the skin, such as what is left after a vesicle ruptures.
A client asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be lower than previous higher than previous within an afebrile range within a subnormal range
lower than previous Explanation: Feeling cold, goosebumps, and shivering accompany a rising temperature, while feeling hot and sweating accompany a falling temperature.
The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the ethmoidal sinuses. laryngeal sinuses. maxillary sinuses. sphenoidal sinuses.
maxillary sinuses. Explanation: The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse.
A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse? "Client depressed because of fear of breast biopsy" "Client with lower back pain" "Client has unkempt appearance and avoids eye contact" "Client has good lung sounds in right and left lungs"
"Client has unkempt appearance and avoids eye contact" Explanation: Unkempt appearance and avoiding eye contact are specific observations that are easily understood. The nurse cannot diagnose depression. "Lower back pain" represents incomplete data, and describing lung sounds as "good" is not using appropriate terminology.
A nurse performs a focused assessment on a client reporting increased shortness of breath. The nurse uses COLDSPA to learn more about the client's symptoms. Which statement(s) by the client would require verification? Select all that apply. "I cannot lie flat when sleeping." "I started having shortness of breath a few weeks ago." "Walking upstairs and long distances increases my shortness of breath." "My diet has not changed." "I haven't gained or lost any weight."
"I cannot lie flat when sleeping." "I started having shortness of breath a few weeks ago." "Walking upstairs and long distances increases my shortness of breath." Explanation: The nurse would want to learn more about not being able to lie flat and whether that also occurred a few weeks ago. The shortness of breath started a few weeks ago; the nurse should investigate whether the client made any life changes or whether something occurred (such as an injury). The nurse would further investigate the client's shortness of breath, such as inquiring how many stairs and the distance in which the shortness of breath occurs. Not having any changes in diet or weight does not require further investigation.
While conducting a general survey, the nurse observes that the client looks tired and disheveled. Which statement by the client requires further follow-up? "I generally get 8 to 9 hours of sleep every night." "I eat a well-balanced diet." "My bowel movements have been regular." "I work 8 to 10 hours a day during the week."
"I generally get 8 to 9 hours of sleep every night." Explanation: The nurse's observation of the client looking tired and disheveled does not match the client's statement of "I generally get 8 to 9 hours of sleep every night." The nurse needs to investigate this more; for example, "Did something happen recently that is preventing you from getting 8 hours of sleep?"; "How would you describe your sleep; for example, is it sound or restless, do you awaken several times a night?"; and "Have you been or are you experiencing pain?" The other client statements do not indicate anything abnormal and do not conflict with the nursing observations. Reference:
The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement? "Confidentiality is a right you have as a client." "I have to share the information if it reveals something that could hurt you." "Don't share anything with me that you don't want your health provider to know." "I'm ethically bound to keep your health information confidential."
"I have to share the information if it reveals something that could hurt you." Explanation: The principle of confidentiality is of paramount importance in the nurse-client relationship. The nurse is obligated to protect client information and to share it only with appropriate health care team members. But the client must be told that any information provided that appears to be harmful to either the client or anyone else must be shared with the appropriate person or persons.
A client who is being treated for depression and hypertension comes to the clinic for a checkup. The nurse performs a general survey. Which statement from the client requires further follow-up by the nurse? "I have gained 5 lbs over the past 6 months." "I take my herbal supplements every day." "I usually have a bowel movement every 2 days." "I drink about 3 cups of coffee each day."
"I take my herbal supplements every day." Explanation: It is important to obtain a list of all medications including over-the-counter medications and herbal supplements. Because the client is being treated for depression and hypertension, herbal supplements may interfere with the medications' effectiveness or cause adverse interactions. Gaining 5 lbs in 6 months is not excessive weight gain. People have different bowel patterns; a bowel movement every 2 days is not a concern. Drinking 3 cups of coffee a day is not excessive and is not a concern.
The nurse is conducting a history of the present illness. Which statement represents a possible response by the client? Select all that apply.\ "I want to be able to sleep on my left side." "My pain is a 7 all the time." "Climbing stairs makes my pain worse." "I am able to dress myself." "I walk 2 miles every day."
"I want to be able to sleep on my left side." "My pain is a 7 all the time." "Climbing stairs makes my pain worse. Explanation: The nurse conducting a history of the present illness includes six elements of symptom analysis: location, duration, intensity, quality/description, aggravating/alleviating factors, pain goal, and functional goal. "I want to be able to sleep on my left side" is a functional goal. Intensity is reflected in the statement rating the pain as 7. The client statement about stair climbing identifies an aggravating factor. The client statements about ability to dress self and walking 2 miles every day are data cues that pose no problem for the client.
When assessing the oxygen saturation of a client with chronic obstructive pulmonary disease (COPD), the nurse notes an SpO2 reading of 100%. The client asks about the significance of this result. How should the nurse respond? "This means the amount of oxygen in your blood is higher than it should be optimally." "The amount of hemoglobin filled with oxygen is too low." "This is within the acceptable range for someone with COPD." "A higher oxygen saturation result is better than a lower one."
"This means the amount of oxygen in your blood is higher than it should be optimally." Explanation: The nurse should respond with the statement, "This means the amount of oxygen in your blood is higher than it should be optimally." Hyperoxemia is an abnormal finding that requires further follow-up by the nurse. Hypoxia, not hyperoxemia, refers to when the amount of hemoglobin filled with oxygen is too low. Hyperoxemia, or an oxygen saturation reading of greater than 99 percent, is an abnormal finding. Therefore, the nurse should not reply with the statement "A higher oxygen saturation result is better than a lower one," because this is not universally true.
Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? "Our schedule is very busy also. We got to you as soon as we could." "No one is holding you captive, you are free to leave at any time." "Would you like to speak to the office manager about your complaint?" "You seem very angry. I am ready to begin your exam now."
"You seem very angry. I am ready to begin your exam now." Explanation: When the nurse encounters an angry client, it is best to acknowledge the feelings of the client in a calm, reassuring, and in-control manner. Telling the client that the schedule is busy, that no one is holding him or her captive, or asking if he or she would like to speak to the office manager are inappropriate and do not acknowledge the client's feelings.
The nurse reviews temperature measurements for assigned clients. Which measurement should the nurse identify as being elevated? 99.5 F oral 100.5 F rectal 97.9 F axillary 100.1 F temporal
100.5 F rectal Explanation: The oral, axillary, and temporal temperature measurements are all within normal limits. A rectal temperature higher than 100.3 F is considered elevated.
The nurse reviews temperature measurements for assigned clients. Which measurement should the nurse identify as being elevated? 99.5 F oral 100.5 F rectal 97.9 F axillary 100.1 F temporal
100.5 F rectal Explanation: The oral, axillary, and temporal temperature measurements are all within normal limits. A rectal temperature higher than 100.3 F is considered elevated.
A client had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route? 102.4°F 99.6°F 98.6°F 103.8°F
102.4°F Explanation: The tympanic membrane thermometer measures core body temperature, which is higher than the normal oral temperature by approximately 1.4°F. The nurse will most likely obtain a body temperature of 102.4°F for the client. The temperature 99.6°F is 1.4°F lower than the oral temperature. The temperature 98.6°F is considered a normal body temperature. The temperature 103.8°F is a difference of 2.8°F and not expected if using a tympanic membrane thermomete
Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore? 9 or lower 10 to 12 13 to 18 19 to 23
19 to 23 Explanation: Levels of risk for developing pressure ulcers are rated according to the following scores: • 19 to 23: not at risk • 15 to 18: mild risk • 13 to 14: moderate risk • 10 to 12: high risk • 9 or lower: very high
The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis? To diagnose the condition and particular illness of the client. A clinical judgment about client responses to health difficulties. The collection of subjective and objective data. Identification of realistic, client-centered goals.
A clinical judgment about client responses to health difficulties. Explanation: Diagnosis is the clustering of data to make a judgment or statement about the client's difficulty or condition. NANDA International (NANDA-I, 2012) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."
Common or concerning symptoms to inquire about in the general survey and vital signs include all of the following except: Weight Level of consciousness Adventitious lung sounds Fever
Adventitious lung sounds Explanation: Auscultating the lungs is more appropriate during the respiratory review of systems. Weight, temperature, and level of consciousness are all components of the general survey and vital signs.
The nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client's BP to be higher. The client is not taking any medications. What do you think is causing this BP reading? An auscultatory gap A cuff size error The client's emotional state Resolution of the process that caused her retinopathy and kidney problems
An auscultatory gap Explanation: The blood pressure is unusual in this case because the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, the nurse should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a client with a small arm, this does not account for the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process that caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this client.
When assessing a client's lips, which of the following is an indication of a viral infection? Aphthous ulcer Edema Cracking Swelling
Aphthous ulcer Explanation: Dryness or cracking of the lips may indicate inadequate hydration. Lesions or aphthous ulcers may represent a viral infection. Swelling or edema of lips suggests allergy.
During one of your clinical placements you encounter a client who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.) Appear attentive Give brief encouragement to the client Change the subject you are asking about Ask your question again Watch the client closely for nonverbal cues
Appear attentive Give brief encouragement to the client Watch the client closely for nonverbal cues Explanation: The period of silence usually feels much longer to the nurse than it does to the client. The nurse should appear attentive and give brief encouragement to continue when appropriate. During periods of silence, watch the client closely for nonverbal cues, such as difficulty controlling emotions. Repetition may make the client more uncomfortable and further hinder communication. The nurse should implement the other listed techniques before changing the subject.
The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply Appetite good Right foot swollen Vital signs normal Rates pain as a 6 on a scale of 1 to 10 Reddened area 1 cm x 2 cm on left upper thigh
Appetite good Right foot swollen Vital signs normal Explanation: The manager should question vague documentation such as appetite good, right foot swollen, and vital signs normal. Details should be documented such as the location and size of a reddened area and the objective rating that a client provides about pain level.
A nurse is performing a comprehensive assessment on a client. The nurse observes excessive sweat and body odor. How should the nurse address these findings? Ask the client if they were partaking in something very physical before the appointment. Ignore the findings; the nurse would insult the client if these issues were addressed. Ask the client if they experience periods of excessive sweating. Ask the client about their bathing and hygiene regimen.
Ask the client if they experience periods of excessive sweating. Explanation: The nurse needs to address this finding becuase they could be the result of some underlying condition. The nurse should ask questions in a nonjudgmental, straightforward manner, being sensitive to the client's feelings. Asking if the client was partaking in physical activity prior to arriving at the appointment is not the best way to address these findings. The nurse may ask about hygiene regimen but this is not the best answer.
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? Ask the client to identify which medications taken every day. Ask the client to bring all the medications and supplements to an interview. Ask the caregiver whether the client is taking prescribed medications. Ask the client about the use of any over-the-counter medications.
Ask the client to bring all the medications and supplements to an interview. Explanation: Bringing all medications to the interview allows the nurse to verify medications and evaluate any potential problem. The client may inadvertently forget to mention over-the-counter medications or herbal substances if asked to identify the medications taken, focusing on only those that are prescribed. Asking the caregiver is a beginning point if the client is having difficulty remembering what he or she takes, but it is best to have the client or caregiver bring all the medications the client is taking. The nurse needs to gather information about all medications, not just over-the-counter ones.
A nurse in a clinic performs an assessment on a 73-year-old client. The client's vital signs are as follows: tympanic temperature 95.9° F (35.5° C), palpated radial pulse 93 beats/min irregular, blood pressure 110/43 mm Hg (right arm) and 100/40 mm Hg (left arm), and respiratory rate 20 breaths/min. What action should the nurse take? Document as normal findings for an older adult. Assess the apical pulse for 1 full minute. Notify the health care worker of blood pressure irregularities. Take a rectal temperature.
Assess the apical pulse for 1 full minute. Explanation: The apical pulse should be checked for 1 full minute when an irregular pulse is observed. The other findings are normal for an older adult and do not require action; for example, temperatures can range from 95° F to 97.5° F (35° C to 36.38° C), respirations can range from 15 to 22, blood pressures will have widened pulse pressure due to atherosclerosis as seen here (100/40 and 110/43 mm Hg), and a blood pressure difference of 10 mm Hg between arms is normal in adults.
The nurse is about to leave the floor for her lunch break. Before leaving she must report using the SBAR model to the nurse who is to care for the client during her absence. She tells the nurse, "The client was admitted 8 hours ago after spending the night in the ER with abdominal and back pain. He has had numerous tests; results indicate that he has gallstones. He is scheduled for surgery tomorrow." What part of the SBAR model does this information represent? Situation Background Assessment Recommendation
Background Explanation: The model known as SBAR is for improving communication between and among clinicians. The S stands for situation--why the nurse is communicating; B stands for background--the circumstances leading up to current situation; A is for assessment--objective and subjective data pertinent to the situation; and R is for recommendation--the nurse's suggestions of what needs to be done to manage the problem. In this case, the nurse gave background information when reporting.
The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except: Apparent age Signs of distress Dress, grooming, and personal hygiene Blood pressure
Blood pressure Explanation: Blood pressure is a vital sign, not part of the general survey. Apparent age, signs of distress, and appearance are all parameters of the general survey.
A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? Charting by exception Focus charting Problem, Intervention, Evaluation (PIE) charting Variance charting
Charting by exception Explanation: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. Focus charting does not use a problem list of nursing or medical diagnoses but incorporates many aspects of the client and client care into a focus column. The focus may be a client strength, problem, or need. Problem, Intervention, Evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome or a planned intervention is not implemented in the case management model.
A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data? Have the client weighed again on the same equipment. Verify the previously documented data. Compare objective findings with subjective findings. Avoid questioning the client on the sudden weight gain.
Compare objective findings with subjective findings. Explanation: The nurse should compare the objective findings (i.e., the client's weight) with subjective findings (i.e., what the client says about her weight gain) to uncover any discrepancies. The nurse should have the client weighed again on a different scale, not the same one, to rule out equipment error. The nurse may not be able to verify the previously documented data; the nurse who conducted the assessment at that time must have ensured that it was right. The nurse should clarify data with the client by asking additional questions to support the objective data.
A client is being admitted to a rehabilitation facility after having a stroke. Which type of assessment should the nurse complete with this client? Focused Follow-up Comprehensive Problem-oriented
Comprehensive Explanation: When admitting a client to facility, a comprehensive assessment is completed. This assessment includes current health problems, past history, family history, a review of body systems, and health patterns. It provides a basis for assessing client concerns, health status, risk factors, and health promotion. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. Reference:
A 14-year-old boy has a rash at his ankles. There is no history of exposures to ill people or environmental agents. He has a slight fever. The rash consists of small, bright red marks. When they are pressed, the red color remains. What should the nurse do? Prescribe a steroid cream to decrease inflammation. Consider admitting the client to the hospital. Reassure the parents and the client that this should resolve within 1 week. Tell him not to scratch them and follow up in 3 days.
Consider admitting the client to the hospital. Explanation: Although this rash may not be impressive, the fact that they do not blanch with pressure is concerning. This generally means that there is pinpoint bleeding under the skin; while this can be benign, it can be associated with life-threatening illnesses like meningococcemia and low platelet counts (thrombocytopenia) associated with serious blood disorders like leukemia. The nurse should always report this feature of a rash immediately.
During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation? Determining whether the client wants to stop smoking Educating the client on the detrimental effects smoking has on the entire body. Identifying smoking as a modifiable risk factor for the client. Sharing with the client that there are various smoking cessation methods available.
Determining whether the client wants to stop smoking Explanation: Smoking cessation requires a dramatic change in behavior. The client must be truly motivated in order for such a change to occur. The nurse should initially discuss with the client if smoking cessation is a goal that the client may have. If the client is interested in no longer smoking, the remaining options are less relevant. Explaining the detrimental effects of smoking, identifying smoking as a modifiable risk factor and educating the client to the various smoking cessation methods are beneficial when discussing the situation with a client who has not yet made the decision to stop smoking.
The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching? Cover your nose and mouth with your hands when coughing or sneezing Dispose of tissues directly into trash cans Wash your hands before coming into contact with another person Take medicine when you cannot stop coughing
Dispose of tissues directly into trash cans Explanation: Clients and other people with symptoms of a respiratory infection are asked to cover their mouths/noses when coughing or sneezing, but not covering the nose and mouth with their hands. Additionally, clients should dispose of tissues directly into trash cans and perform hand hygiene after hands have been in contact with respiratory secretions. The nurse does not teach to use hands to cover the face when sneezing or coughing—the client should instead cough or sneeze into a sleeve. Washing hands before coming into contact with another person is not part of client teaching for a person with pneumonia. Taking medicine when you cannot stop coughing does not answer the question.
The nurse is preparing to examine a client's skin. What would the nurse do next? Ensure that the room is hot to prevent chilling. Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Have the client remove clothing from the upper body.
Expose only the body part that is being examined. Explanation: When preparing to examine a client's skin, the nurse would expose only the body part to be examined to ensure privacy. The room should be at a comfortable temperature, one that is not too warm or too cool. Gloves are needed when palpating any lesions. The client needs to remove all clothing and jewelry and put on an examination gown.
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use? Focused Assessment flow chart Progress notes Nursing minimum data set
Focused Explanation: Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. Examples include cardiovascular or neurologic assessment documentation forms. An assessment flow chart allows for rapid comparison of recorded assessment data from one time period to the next. Progress notes may be used to document unusual events, responses, significant observations, or interactions because the data are inappropriate for flow records. The nursing minimum data set form has a cued format that prompts the nurse for specific criteria; it is usually computerized and is commonly used in long-term care facilities.
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? Open-ended form Focused assessment form Frequent assessment form Ongoing assessment form
Focused assessment form Explanation: The nurse most likely would be using a focused assessment form, one that focuses on the neurologic system because the clients have a specific problem related to neurologic function. An open-ended form would be used for an initial assessment. A frequent or ongoing assessment form could be used to document vital signs or other assessment data to allow rapid comparison of recorded assessment data from one time period to the next.
A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? General Appetite Rest and sleep Gastrointestinal
General Explanation: Information to document under the general area includes usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, or fever. Information about weight and fatigue is not documented under the gastrointestinal system. Appetite and rest and sleep are not areas within the review of systems.
A nurse obtains a client's blood pressure (BP) on admission in both arms: Right arm BP 130/75 mmHg and left arm BP 140/80 mmHg. Which arm should the nurse use for subsequent blood pressure reading? Left arm Right arm Dominant arm Both arms
Left arm Explanation: Blood pressure should be taken in the dominant arm first. When assessing for the first time, BP should be measured in both arms. Subsequent readings should be taken in the arm with the highest measurement.
A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information? History of allergies History of dysphagia Frequency of nosebleeds Tonsillar enlargement
History of allergies Explanation: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Dysphagia would suggest a problem with the throat. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa , hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis.
A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client? Onset of iron deficiency anemia History of cigarette smoking Environmental exposure to chemicals Treatment for fungal infections in the past
History of cigarette smoking Explanation: An increase in the angle between the nail base and the skin is seen in clients with clubbing which occurs from hypoxia to the tissue secondary to cigarette smoking. Iron deficiency will produce nails that are spoon shaped in appearance. Exposure to chemicals can cause the nails to be excessively dry or to have splinter hemorrhages due to trauma to the nail bed. Fungal infections can cause a yellow discoloration to the nails.
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? Impetigo Psoriasis Herpes zoster Viral Exanthem
Impetigo Explanation: Honey colored exudate in a vesicular rash is indicative of impetigo. Most often, a child scratches a bug bite or other lesion that becomes infected with bacteria. These bacteria then produce the characteristic honey colored exudate. Psoriasis does not produce exudate; is not a vesicular rash. It is produced from desquamation of dead epithelial cells. Herpes zoster can produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash. A viral exanthem is a macular or papular rash that is present along with a viral infection
Assessing a client's cognition is part of the general assessment. What is the strongest indicator of a cognitive disorder in a client? Impaired long-term memory Ability to perform selected ADLs Inappropriate affect Overattentiveness
Inappropriate affect Explanation: Inappropriate affect, inattentiveness, impaired memory, and inability to perform ADLs may indicate dementia (e.g., Alzheimer's disease) or another cognitive disorder. Therefore, the other options are incorrect and do not indicate dementia.
A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic? Increased thickness and hair loss Increased thinness Pallor Erythema
Increased thinness Explanation: Thin skin is most likely to be assessed because of decreased protein and subcutaneous fat secondary to glucocorticoid drugs. The skin would not likely be pale, thick, or erythemic.
During an integumentary assessment, the nurse notes that the client's fingernails are very thin and concave. The nurse knows the client needs medical follow-up for further assessment to rule out which condition? Diabetes mellitus Iron deficiency anemia Vitamin A deficiency Peripheral vascular disease
Iron deficiency anemia Explanation: Spoon nails or nails that are thin and concave are associated with iron deficiency, not vitamin A deficiency, peripheral vascular disease, or diabetes mellitus.
A nurse is using a nursing minimum data set to document findings following the assessment of a client. This nurse is most likely providing care in which setting? Acute care facility Long-term care facility Urgent care center Health clinic
Long-term care facility Explanation: A nursing minimum data set is the format used most commonly in long-term care facilities. The format for assessment documentation would vary among acute care facilities, urgent care centers, and health clinics.
The nurse is examining an unconscious client from another country and notices Beau's lines, a transverse groove across all of her nails, approximately 1 cm from the proximal nail fold. What would the nurse do next? Conclude this is caused by a cultural practice. Conclude this finding is most likely secondary to trauma. Look for information from family and records regarding any problems that may have occurred at least 3 months ago. Ask about dietary intake.
Look for information from family and records regarding any problems that may have occurred at least 3 months ago. Explanation: These lines can provide valuable information about previous significant illnesses, some of which are forgotten or not able to be reported by the client. Because the fingernails grow at approximately 0.1 mm per day, the nurse would ask about an illness 100 days ago. This client may have been hospitalized for endocarditis or may have had another significant illness. Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a client's culture without good knowledge of that culture.
A nurse performs indirect palpation of an underlying structure correctly when the hands are placed in which position? 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface Middle finger of one hand is placed on the body surface and the other middle finger strikes Ulnar surface of one hand is placed against the body surface and vibrations are felt One hand is placed flat against the body and the fist of the other hand strikes the back of the flat hand
Middle finger of one hand is placed on the body surface and the other middle finger strikes Explanation: Indirect percussion is the most commonly used of the percussion techniques. This method entails the middle finger of the nondominant hand to be placed on the body surface to be assessed. Keeping all other fingers off the body surface, strike this finger with the other middle finger. Direct percussion is when 1-2 fingers are placed over the body structure and the fingertips are used to tap the skin surface. Placing the ulnar surface of one hand against the body surface and feeling the vibrations is a form of palpation. Blunt palpation involves placing one hand flat against the body and the fist of the other hand strikes the back of the flat hand.
The nurse notes which of the following vital sign findings as an abnormal finding in an 88-year-old client? 50 mm Hg pulse pressure. Respiratory rate of 22 breaths/minute. Oral temperature of 37.6 °C (99.6 °F). Blood pressure of 140/90 mm Hg.
Oral temperature of 37.6 °C (99.6 °F). Explanation: A temperature of 99.6 F (37.6 C) is an abnormal value. In the older adult, the respiratory rate may range from 15 to 22. Pulse pressure is expected to be between 30 and 50 mm Hg though it can be higher for older adults. A blood pressure of 140/90 mm Hg is normal for an older adult.
The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding? Hypoxia Recent trauma Iron deficiency Normal finding
Normal finding Explanation: Longitudinal or parallel ridges in the nails may be seen in the elderly and some young people and have no known etiology. Nail clubbing would indicate hypoxia. Splinter hemorrhages would indicate recent trauma. Spoon-shaped nails are associated with iron-deficiency anemia.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use? Open-ended forms Cued or checklist forms Integrated cued checklist Nursing minimum data set
Nursing minimum data set Explanation: The nursing minimum data set establishes comparability of nursing data across clinical populations, settings, geographic areas, and time. Open-ended forms, cued or checklist forms, and integrated cued checklists do not provide such comparability of nursing data.
A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? Emergency Ongoing Focused Comprehensive
Ongoing Explanation: Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.
The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? Resonance on percussion Dull sounds Tympanic sounds Pain on percussion
Pain on percussion Explanation: The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection. Percussion is not performed in an effort to gauge particular sounds.
A nurse recognizes that the best part of the hand to use to palpate for vibration is: Finger tips Palmar surface Dorsal surface Finger pads
Palmar surface Explanation: The ulnar or palmar surface is the part of the hand used to palpate vibrations. The finger tips are not used to palpate. The dorsal surface is sensitive to temperature and the finger pads are used to detect fine discriminations, pulses, texture, size, consistency, shape, & thrills.
A nurse finds a radial pulse that is weak and thready. What action should the nurse take next? Palpate the carotid arteries Auscultate heart sounds Report the finding to the health care provider Document the findings
Palpate the carotid arteries Explanation: A weak and thready pulse is abnormal and the nurse should assess the carotid pulses because they are the best assessment of contour and amplitude. This is due to their proximity to the heart and the pulse wave of the carotid pulse coincides closely with ventricular systole.
An adolescent shows the nurse a "bump" on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. How would the nurse document this finding? Macule Papule Nodule Pustule
Papule Explanation: A papule is a solid, elevated, circumscribed skin lesion that does not contain serous or purulent fluid. A macule is a flat nonpalpable skin color change usually less than 1 cm in size. A nodule is an elevated solid palpable mass between 0.5 to 2 cm in size. A pustule is pus-filled vesicle or bulla (circumscribed elevated mass).
A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease? Chronic obstructive pulmonary disease (COPD) Parkinson's disease Lordosis of the cervical spine Multiple sclerosis
Parkinson's disease Explanation: A stiff, shuffling, rigid gait is seen in persons with Parkinson's disease due to the destruction of dopamine receptors in the brain that maintain balance between contraction and relaxation of the muscles. COPD clients have no problems with gait except that activity makes them short of breath. Lordosis of the spine is seen in pregnant women occurs in the lumbar area of the spine due to the weight of the developing fetus. Multiple sclerosis causes muscle weakness not rigidity.
Which would the nurse recognize as an example of data found in the background section of the SBAR reporting format? The client was admitted at 0300 with complaints of severe headache, nausea, and vomiting. Pain rating was 10; blood pressure was 150/90. The client received sumatriptan (Imitrex) at 0430. Last episode of vomiting was 0500. Patient was diagnosed with migraine headaches 2 years ago. Pain rating is 4; blood pressure is 130/80. A neurology consult is needed.
Patient was diagnosed with migraine headaches 2 years ago. Explanation: The client's diagnosis of migraines 2 years ago is the background information of the example. The situation is the admission of the client and the assessment data at that time. The assessment is the client's current pain rating and blood pressure. The recommendation is for a neurology consult.
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What would the nurse do next? Document the benign findings. Perform a random blood sugar test. Ask the client about a family history of cancer. Refer the client for medical follow-up.
Perform a random blood sugar test. Explanation: Linear hyperpigmented areas (Acanthosis nigricans) present in the skin of the neck, axillae, and perianal folds in dark-skinned people suggest diabetes mellitus. A random blood sugar test would provide an objective assessment to identify hyperglycemia. The findings are not indicative of skin cancer, nor are they benign. The client may be referred for medical follow up after additional assessment is completed.
While completing the review of systems, a client reports a major health event that has yet to be mentioned. In which area should the nurse document this information? Present illness Family history Health patterns Review of systems
Present illness Explanation: The review of systems questions may uncover problems that the client has overlooked, particularly in areas unrelated to the present illness. Major health events should be recorded under the Present Illness or Past History in the documentation. A major health event should not be documented under family history, health patterns, or review of systems.
The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? Reassess previously detected problems Provide information for the client's record Address areas previously omitted Determine the need for crisis intervention
Reassess previously detected problems Explanation: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.
Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? Pink, moist, firm Red, bleeding Enlarged, reddened A grey-white line
Red, bleeding Explanation: Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. A grey-white line along the gum line is seen in cases of lead poisoning.
Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process? Deviated septum Peritonsillar abscess Candidiasis Tongue fissures
Tongue fissures Explanation: Fissures may appear in the tongue with increasing age.
The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens? Use of alcohol-based hand cleaner Respiratory/cough hygiene How to recycle personnel protective equipment How to clean client equipment
Respiratory/cough hygiene Explanation: Respiratory hygiene/cough etiquette is another area that the CDC is addressing. Patients and other people with symptoms of a respiratory infection are asked to cover their mouths and noses with a tissue when coughing or sneezing.
The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition? The client is demonstrating central cyanosis. The cyanosis may be a result of a prolonged period of exposure to the cold. The client's arterial blood will appear bluish when observed in the test tube. The cyanosis is a result of body tissue extracting less than usual amounts of oxygen from the blood.
The cyanosis may be a result of a prolonged period of exposure to the cold. Explanation: Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the client. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a response to anxiety or a cold environment. The bluish color of a subcutaneous vein is not the trigger for this form of cyanosis.
The nurse is assessing the older adult for anosmia. Which nursing action would the nurse perform? The nurse asks the client to identify common scents. The nurse palpates the maxillary sinus areas. The nurse instructs the older adult to say "ah." The nurse inspects the buccal mucosa and tongue.
The nurse asks the client to identify common scents. Explanation: Anosmia is a loss of smell. The nurse would ask the client to identify common scents. The nurse instructs the older adult to say "ah" to assess the function of the vagus nerve (CN X). Palpation of the maxillary sinus areas should not elicit tenderness or fullness, which are suggestive of infection (sinusitis). The nurse would inspect the buccal mucosa and tongue to identify poor oral hygiene, infection, and trauma.
The nurse is assessing the client's vagus nerve (CN X). Which nursing action would the nurse perform? The nurse instructs the older adult to say "ah." The nurse asks the client to identify common scents. The nurse palpates the maxillary sinus areas. The nurse inspects the buccal mucosa and tongue.
The nurse instructs the older adult to say "ah." Explanation: The nurse instructs the older adult to say "ah" to assess the function of the vagus nerve (CN X). Palpation of the maxillary sinus areas should not elicit tenderness or fullness, which are suggestive of infection (sinusitis). The nurse would inspect the buccal mucosa and tongue to identify poor oral hygiene, infection, and trauma. The nurse would ask the client to identify common scents to assess for a loss of smell.
A 19-year-old construction worker presents for evaluation of a rash. He says that it started on his back with a multitude of spots and is also on his arms, chest, and neck. It itches a lot. He has been sweating more than before, because being outdoors is part of his job. Physical examination reveals dark tan and reddish patches with sharp borders and fine scales, scattered more prominently around the upper back, chest, neck, and upper arms as well as under the arms. Based on this description, what is the most likely diagnosis? Pityriasis rosea Tinea versicolor Psoriasis Atopic eczema
Tinea versicolor Explanation: This is a typical description of tinea versicolor. The information that the client is sweating more also helps support this diagnosis, because tinea is a fungal infection and promoted by moisture.
What is the principle of percussion? To assess the sound created by the body To strike the abdominal wall with a soft object To create sound over dead spaces in the body To create vibration in a body wall
To create vibration in a body wall Explanation: The principle of percussion is to set the chest wall or abdominal wall into vibration by striking it with a firm object. Options A, B, and C are incorrect because they are not considered the principle of percussion.
A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply. To eliminate the possibility of diagnosing new problems To ensure that only the nurse is aware of the assessments To prevent delays in carrying out the plan of care To determine the educational needs of the client
To prevent delays in carrying out the plan of care To determine the educational needs of the client Two of the reasons the nurse should document assessment findings are to determine the educational needs of the client and to prevent delays in carrying out the plan of care. Documentation acts as a source of information to help diagnose new problems rather than eliminating the possibility of diagnosing new problems. Documentation ensures that the information is accessible to all members of the health care team, not just the nurse; this enables effective communication between the team members.
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action? To check the client for skin lesions the client may not be aware of To overhear the client's conversation with a family member To see the client before the client assumes a social face or behavior To determine whether you recognize the client from a previous visit
To see the client before the client assumes a social face or behavior Explanation: If possible, try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to see the client before the client assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain before the client, knowingly or unknowingly, may mask it. An initial observation of the client from a distance would not be effective for assessing for skin lesions. Trying to overhear the client conversation with a family member would be inappropriate. You may determine whether you recognize the client from a previous visit by a quick observation, but this is not the primary rationale for this action.
An older client's blood pressure is 148/60 mm Hg. What should this finding indicate to the nurse? Normal blood pressure Inappropriate use of diuretics Orthostatic blood pressure changes Undiagnosed cardiovascular disease
Undiagnosed cardiovascular disease Explanation: Since the blood pressure is 148/60, the pulse pressure is 148-60 = 88. A normal pulse pressure is between 30 - 50 mm Hg. A pulse pressure greater than 50 mm Hg could indicate cardiovascular disease. It may also be a normal finding in an older client due to less elastic peripheral arteries. This is not considered a normal blood pressure. There is no evidence to support that the client is taking diuretics. There is not enough information to determine if the client is experiencing orthostatic blood pressure changes.
The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply. Validate data Document data Collect objective data Analyze outcome data Collect subjective data
Validate data Document data Collect objective data Collect subjective data The assessment phase of the nursing process has four major steps: collect subjective data; collect objective data; validate data; and document data. Analyzing outcome data is performed during the evaluation phase of the nursing process.
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Cool and dry expired air Move mucus to the back of the throat Moisten and filter expired air Warm and humidify inspired air
Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucous in the nasal cavities and filter the inspired air.
An adolescent client presents to the health clinic for a routine physical examination. Which observation by the nurse needs validation by collection of objective data? Wearing long sleeve clothing in July Clean and well groomed appearance Body odor from the axilla area Skin warm and flushed in appearance
Wearing long sleeve clothing in July Explanation: Dress should be appropriate for the weather. Wearing a long sleeve shirt in July in an adolescent may be signs of covering up needle marks. Clean and well groomed is normal. Adolescents often have a strong body odor due to the onset of activity within the apocrine glands. Flushed appearance of the skin is likely due to the excessively warm clothes for the season.
When should the nurse perform hand hygiene? Select all that apply. When hands are visibly soiled After removing gloves After providing mouth care After reconciling the client's medications After taking the blood pressure of a client with intact skin
When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin Explanation: Hand hygiene sometimes means hand washing with soap and water but at other times can involve only decontamination with an alcohol-based hand rub, depending on the circumstance. Hand hygiene is required when the nurse's hands are visibly soiled, after removing gloves, after providing mouth care, and after taking the blood pressure of a client with intact skin. Reconciling the client's medications means comparing the medications the client is prescribed and is actually using to new medications that are ordered to resolve any discrepancies; this activity does not require hand hygiene.
The nurse would perform handoff report for which situation? Select all that apply. When leaving for lunch When sending the client for an endoscopy At shift change Upon transferring to ICU When assessing other clients on the unit
When leaving for lunch When sending the client for an endoscopy At shift change Upon transferring to ICU Explanation: Handoff, or transfer of care of a client from one health care provider to another should occur when there is a transfer of responsibility for the care of the client to another. Lunch breaks, transferring the client to ICU or procedural areas and at shift change all require a handoff. When the nurse is assessing other clients, the nurse retains responsibility for the client and no handoff is needed.
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had chemotherapy. radiation. a recent illness. steroid therapy.
a recent illness. Explanation: Beau's lines occur after acute illness and eventually grow out.
A client is concerned that a blood pressure reading of 180/78 mm Hg is extremely high when the readings usually are around 130/60 mm Hg. What could have caused this elevation in blood pressure? blood pressure cuff too large cuff was deflated too quickly arm below the level of the heart stethoscope not over the brachial artery
arm below the level of the heart Explanation: One reason for a falsely elevated blood pressure is the arm being held below the level of the heart. Reasons for a false low blood pressure include a cuff that is too large, deflating the cuff too quickly, and not placing the stethoscope over the brachial artery.
A client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take? palpate the carotid artery for 15 seconds auscultate the heart rate for a full minute document the pulse as being 84 and irregular palpate the radial pulse again for a full minute
auscultate the heart rate for a full minute Explanation: If the radial pulse is irregular, the apical heart rate should be auscultated for a full minute. There is no need to palpate the carotid artery. Documenting that the pulse is 84 and irregular cannot be validated unless the heart rate is auscultated for a full minute. Palpating the radial pulse for a full minute will not necessarily provide the client's correct pulse rate since pauses are occurring.
Before examining the mouth of an adult client, the nurse should first ask the client to leave dentures in place. don sterile gloves for the procedure. offer the client mouthwash. don clean gloves for the procedure.
don clean gloves for the procedure. Explanation: Before touching any mucous membranes the nurse should apply gloves.
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's: nail beds. oral mucosa. sclera. palms.
oral mucosa. Explanation: Central cyanosis results from a cardiopulmonary problem, whereas peripheral cyanosis may be a local problem resulting from vasoconstriction. To differentiate between central and peripheral cyanosis, look for central cyanosis in the oral mucosa.
The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination? palpation inspection percussion auscultation
percussion Explanation: Percussion is used to illicit sound or determine tenderness. It determines the presence of air, fluid or solid tissues within the lung tissues. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Inspection is used to conduct the general survey, observing for body positioning, appearance, and behavior. Auscultation is used to listen to sounds.
x The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client? heart sounds bowel sounds pulse oximetry body temperature
pulse oximetry Explanation: A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia. Measuring the client's pulse oximetry would be a priority. Heart sounds, bowel sounds, and body temperature will not provide information to determine the cause for the clubbed nails.
A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem? sexual history family history past medical history health maintenance
sexual history Explanation: Although questions about sexual behavior can be used at multiple points in an interview, if the chief complaint involves genitourinary symptoms, questions about sexual health can be included as part of expanding and clarifying the client's story. The issue of repeated urinary tract infections is not appropriate when collecting data about the client's family history, past medical history, or health maintenance. Reference:
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that: melanoma skin cancers are the most common type of cancers. African Americans are the least susceptible to skin cancers. usually there are precursor lesions for basal cell carcinomas. squamous cell carcinomas are most common on body sites with heavy sun exposure.
squamous cell carcinomas are most common on body sites with heavy sun exposure. Explanation: Squamous cell carcinoma is most common on body sites with very heavy sun exposure.
A client with a long history of chronic renal failure is brought to the emergency room after missing a dialysis appointment. Once the client is stabilized and prior to discharge, what information should the nurse obtain from the client? the name of the dialysis center the frequency of the dialysis if there are any caregivers at home the reason for the missed dialysis appointment
the reason for the missed dialysis appointment Explanation: Once the emergency is resolved, the best action of the nurse would be to perform a focused health interview regarding the missed dialysis appointment that led to an emergency situation. The other options—the name of the dialysis center, frequency of the dialysis, and if there are caregivers at home—will not provide the information needed to prevent this occurrence from happening again.
Short, pale, and fine hair that is present over much of the body is termed vellus. dermal. lanugo. terminal.
vellus. Explanation: Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's nodules. bullae. vesicles. wheals.
vesicles. Explanation: Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.
