Fundamentals of nursing test #2 ch. 30, 31, 41, 44, 49
The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."
1. "I'll recognize abnormal lumps because they are very painful."
The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history
1. Appearance and behavior
A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible
1. Calls the health care provider and questions the order
A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements
1. Cuff too small 5. Insufficient time between measurements
An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need. 2. Blood glucose stores are depleted and the cells do not have energy to use oxygen. 3. Carbon dioxide production increases due to hyperventilation. 4. Carbon dioxide production decreases due to hypoventilation.
1. Fever increases metabolic demands, requiring increased oxygen need.
Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.
1. Only the patient should push the button. 3. The PCA system can set limits to prevent overdoses from occurring. 5. Do not push the button to go to sleep.
Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. Adult who has consumed alcoholic beverages 4. Adolescent waking from sleep 5. Three-pack-per-day smoker with pneumonia
1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 5. Three-pack-per-day smoker with pneumonia
The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? 1. Raise the head of the bed to 45 degrees or higher. 2. Get the oxygen saturation with a pulse oximeter. 3. Take the blood pressure and respiratory rate. 4. Notify the health care provider of the shortness of breath.
1. Raise the head of the bed to 45 degrees or higher.
Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? 1. Record the amount and continue to monitor drainage. 2. Notify the physician. 3. Strip the chest tube starting at the chest. 4. Increase the suction by 10 mm Hg.
1. Record the amount and continue to monitor drainage.
A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? 1. Right antecubital and tympanic membrane 2. Right popliteal and rectal 3. Left antecubital and oral 4. Left popliteal and temporal artery
1. Right antecubital and tympanic membrane
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply.) 1. Sharp pleuritic pain that worsens on inspiration 2. Crackles over lung bases of affected lung 3. Tracheal deviation toward the affected lung 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side
1. Sharp pleuritic pain that worsens on inspiration 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side
The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) 1. SpO2 levels 2. Amount, color, and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg
1. SpO2 levels 2. Amount, color, and consistency of sputum production 4. Change in respiratory rate and pattern
A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction
1. Transcutaneous electrical nerve stimulation (TENS) 3. Provide back massage 4. Reposition the patient
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?
16/min
The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation
2, 3, 4, 1
While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the patient coughed. Which finding should the nurse document from the lung assessment? 1. Rhonchi 2. Coarse crackles 3. Sibilant wheeze 4. Pleural friction rub
2. Coarse crackles
Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10
2. Difficulty arousing the patient
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: 1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis
2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy
2. Frequent change of position
Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.) 1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube
2. Oropharyngeal suctioning of a stable patient 4. Permanent tracheostomy tube suctioning
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%
2. Radial pulse rate: 72 and irregular 4. Respiratory rate: 28 5. Oxygen saturation: 99%
The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately 2. Repeat the measurements on both arms using a stethoscope 3. Ask the patient if she has taken her blood pressure medications recently 4. Obtain blood pressure measurements on lower extremities 5. Verify that the correct cuff size was used during the measurements 6. Review the patient's record for her baseline vital signs 7. Compare right and left radial pulses for strength
2. Repeat the measurements on both arms using a stethoscope 6. Review the patient's record for her baseline vital signs
The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Limit intake of cholesterol to less than 400 mg/day. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.
2. Talk with your health care provider about taking a daily low dose of aspirin; 3. Work with your health care provider to develop a regular exercise program; 4. Limit daily intake of fats to less than 25% to 35% of total calories.; 5. Review strategies to encourage the patient to quit smoking.
A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route
2. The time interval
The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? 1. "Tell me where you are." 2. "What can you tell me about your illness?" 3. "Repeat these numbers back to me: 7...5...8." 4. "What does this mean: 'A stitch in time saves nine?'"
3. "Repeat these numbers back to me: 7...5...8."
The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/90 mm Hg 4. 156/82 mm Hg
3. 130/90 mm Hg
Which patient is at highest risk for tachycardia? 1. A healthy basketball player during warmup exercises 2. A patient admitted with hypothermia 3. A patient with a fever of 39.4° C (103° F) 4. A 90-year-old male taking beta blockers
3. A patient with a fever of 39.4° C (103° F)
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the patient's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications
3. Assess the patient's apical pulse and evidence of a pulse deficit
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? 1. Coughing up sputum occasionally 2. Coughing up thin, watery sputum after nebulization 3. Decreased ability to clear airway through coughing 4. Lung sounds clear only after coughing
3. Decreased ability to clear airway through coughing
The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives
3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives
A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.
3. Have the patient relax the foot while lying supine. 5. Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern
3. Intermittent fever pattern
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? 1. Nail polish attracts microorganisms and contaminates the finger sensor. 2. Nail polish increases oxygen saturation. 3. Nail polish interferes with sensor function. 4. Nail polish creates excessive heat in sensor probe.
3. Nail polish interferes with sensor function.
The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2
3. Respiratory rate of 8 breaths/min
A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants
3. Stool softeners
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? 1. Supine with both arms overhead with palms upward 2. Sitting with hands clasped just above the umbilicus 3. Supine with the right arm abducted and hand under the head and neck 4. Lying on the right side, adducting the right arm on the side of the body
3. Supine with the right arm abducted and hand under the head and neck
The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding
3. The amount of daily acetaminophen
The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."
3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.
During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? 1. Nodule 2. Macule 3. Wheal 4. Pustule
3. Wheal
The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.
4, 1, 3, 2, 5
Place the following in correct sequence for suctioning a patient. 1. Open kit and basin 2. Apply gloves 3. Lubricate catheter 4. Verify functioning of suction device and pressure 5. Connect suction tubing to suction catheter 6. Increase supplemental oxygen 7. Reapply oxygen 8. Suction airway
4, 6, 1, 3, 2, 5, 8, and 7
Which statement made by the patient indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a computed tomography (CT) colonoscopy every 5 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 50."
4. "I'll make sure to have a fecal occult blood test annually once I turn 50."
A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? 1. "I'll make sure that I rest between activities so I don't get so short of breath." 2. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." 3. "If I have trouble breathing at night, I'll use two or three pillows to prop up." 4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: 1. Palpable, elevated hardened area around a tuberculosis skin testing site 2. Sputum for culture and sensitivity identifies mycobacterium tuberculosis 3. Presence of acid-fast bacilli in sputum 4. Arterial oxygen tension (PaO2) of 95 mm Hg
4. Arterial oxygen tension (PaO2) of 95 mm Hg
For which of the following health problems is a patient who has a 40-year history of smoking at risk? 1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress-related illnesses 4. Cardiopulmonary disease and lung cancer
4. Cardiopulmonary disease and lung cancer
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness
4. Decreased activity tolerance and increased breathlessness
A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and 531swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? 1. Direct the NAP to hold the thermometer in place with her gloved hand 2. Direct the NAP to switch the thermometer probe to the left sublingual pocket 3. Direct the NAP to obtain a right tympanic temperature 4. Direct the NAP to use a temporal artery thermometer from right to left
4. Direct the NAP to use a temporal artery thermometer from right to left
A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in the left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases
4. Inspiratory crackles in lung bases
A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal.
4. Opioid withdrawal.
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 112 3. Respiratory rate: 24 4. Oxygen saturation: 96% 5. Blood pressure: 134/78
4. Oxygen saturation: 96%
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit total suctioning time to 5 mins.
A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit total suctioning time to 5 mins.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.
A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward.
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (Select all that apply) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone
A. Furosemide B. Ibuprofen
A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating and relieving factors
A. Presence of associated symptoms
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Pallor
A. Restlessness B. Tachypnea D. Confusion E. Pallor
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply) A. Weber test showing lateralization to the right ear B. Light reflex at 10 oclock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear
A. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things." D. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. "It's still too soon to expect to feel normal. Give it a little more time."
B. "I'm interested in finding out more about how your body feels to you."
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A. "Sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."
B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns."
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image disturbances? (Select all that apply.) A. 30-year-old male following laparoscopic appendectomy B. 45-year-old female following mastectomy C. 20-year-old female following left above-the-knee amputation D. 65-year-old male following cardiac catheterization E. 55-year-old male following stroke with right-sided hemiplegia
B. 45-year-old female following mastectomy C. 20-year-old female following left above-the-knee amputation E. 55-year-old male following stroke with right-sided hemiplegia
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.
B. Assist the client to Fowler's position.
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply) A. Increase the volume of your voice B. Make sure only one person speaks at a time C. Avoid discouraging the client by saying that you do not understand him D. Allow plenty of time for the client to respond E. Use brief sentences with simple words
B. Make sure only one person speaks at a time D. Allow plenty of time for the client to respond E. Use brief sentences with simple words
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."
C. "I should tell the nurse if the pain doesn't stop after I use this device."
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea
C. Bradypnea D. Orthostatic hypotension E. Nausea
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.
C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment B. Put the client in a room with a client who has a hearing loss C. Provide a private room and limit stimulation D. Speak at a higher volume to the client and encourage ambulation
C. Provide a private room and limit stimulation
A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by A. asking what precipitates the pain. B. questioning the client about the location of the pain. C. offering the client a pain scale to measure his pain. D. using open-ended questions to identify the sensation.
C. offering the client a pain scale to measure his pain.
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing."
D. "I don't even want to look at my leg. You can check the dressing."
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids" B. "I clean the ear molds of my hearing aids with rubbing alcohol" C. "I keep the volume of my hearing aids turned up so I can hear better" D. "I take the batteries out of my hearing aids when I take them off at night"
D. "I take the batteries out of my hearing aids when I take them off at night"
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. "Do not measure the client's temperature rectally" b. "Count the client's radial pulse for 30 seconds and multiply it by 2." c. "Do not let the client know you are counting her respirations." d. "Let the client rest for 5 minutes before you measure her blood pressure."
a. "Do not measure the client's temperature rectally"
A nurses caring for a client who asks what her Snellen eye test results mean. The clients visual acuity is 20/30. Which of the following responses should the nurse make? a. "Your eyes see a 20 feet with visually unimpaired eyes see at 30 feet." b. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." c. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." d. "Your left eye can see the chart clearly a 20 feet, and your right eye can see the chart clearly at 30 feet."
a. "Your eyes see a 20 feet with visually unimpaired eyes see at 30 feet."
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous light brown macules on the face
a. Capillary refill less than 3 seconds d. Thick skin on the soles of the feet e. Numerous light brown macules on the face
A nurse is assessing client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Palpating the thyroid in the lower half of the neck b. Visualizing the thyroid on inspection of the neck c. Hearing a bruit when auscultating the thyroid d. Feeling the thyroid ascend as the client swallows e. Finding symmetric extension off the trachea on both sides of the midline
a. Palpating the thyroid in the lower half of the neck d. Feeling the thyroid ascend as the client swallows e. Finding symmetric extension off the trachea on both sides of the midline
A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) a. Posture b. Skin lesions c. Speech d. Allergies e. Immunization status
a. Posture b. Skin lesions c. Speech
A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) a. Smaller nipples b. Less adipose tissue c. Nipple discharge d. More pendulous e. Nipple inversion
a. Smaller nipples d. More pendulous e. Nipple inversion
A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Tympany b. High-pitched clicks c. Borborygmi d. Friction rubs e. Bruits
a. Tympany b. High-pitched clicks
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (select all that apply) a. obtain culture specimens before initiating antimicrobials b. restrict the client's oral fluid intake c. encourage the client to rest and limit activity d. allow the client to shiver to dispel excess heat e. assist the client with oral hygiene frequently
a. obtain culture specimens before initiating antimicrobials c. encourage the client to rest and limit activity e. assist the client with oral hygiene frequently
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply). a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate d. count the rate for 30 sec if it is irregular e. count and report any sighs the client demonstrates
a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate
a nurse is performing a neurosensory examination for a client. which of the following tests should the nurse perform to test the clients balance? select all that apply a. romberg test b. heel to toe walk c. snellen test d. spinal accessory function e. rosenbaum test
a. romberg test b. heel to toe walk
A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination should she perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion
b. Auscultation
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor b. Cyanosis c. Jaundice d. Erythema
b. Cyanosis
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) a. Pull the auricle down and back. b. Insert the speculum slightly down and forward. c. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). d. Make sure the speculum does not touch the ear canal. e. Use the light to visualize the tympanic membrane in a cone shape
b. Insert the speculum slightly down and forward. d. Make sure the speculum does not touch the ear canal. e. Use the light to visualize the tympanic membrane in a cone shape
(Tenting is a delay in the skin returning to its normal place after pinching.) A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) a. Thin, parchment-like skin b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity e. Excessive wrinkling
b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity
A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) a. Collect the data in one continuous session. b. Plan to allow plenty of time for position changes. c. Make sure the client has any essential sensory aids in place. d. Tell the client to take her time answering questions. e. Invite the client to use the bathroom before beginning the examination.
b. Plan to allow plenty of time for position changes. c. Make sure the client has any essential sensory aids in place. d. Tell the client to take her time answering questions. e. Invite the client to use the bathroom before beginning the examination.
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply.) a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature
b. Skin color c. Edema e. Skin temperature
The nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which is of the following strategies should the nurse use with this client? (Select all that apply.) a. Address the client with the appropriate title and her last name. b. Use a mix of open- and closed-ended questions. c. Reduce environmental noise. d. Have the client complete a printed history form. e. Perform the general survey before the examination
b. Use a mix of open- and closed-ended questions. c. Reduce environmental noise. e. Perform the general survey before the examination
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? a. request a prescription for an antihypertensive medication b. ask the client if she is having pain c. request a prescription for an antianxiety medication d. return in 30 min to recheck the client's blood pressure
b. ask the client if she is having pain
durning a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (select all that apply) a. ventricular gallop b. closure of the mitral valve c. closure of the pulmonic valve d. closure of the tricuspid valve e. murmur
b. closure of the mitral valve d. closure of the tricuspid valve
a nurse is collecting data from an older adult as part of a neurosensory examination. which of the following findings should the nurse expect as changes with aging? select all that apply a. slower light touch sensation b. some vision and hearing decline c. slower fine finger movement d. some short term memory decline e. slower superficial pain sensation
b. some vision and hearing decline c. slower fine finger movement d. some short term memory decline
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include one testing cranial nerve V? (Select all that apply.) a. "Close your eyes." b. "Tell me what you can taste." c. "Clench your teeth." d. "Raise your eyebrows." e "Tell me when you feel a touch."
c. "Clench your teeth." e "Tell me when you feel a touch."
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? a. Palmar surface b. Fingertips c. Dorsal surface d. Base of the fingers
c. Dorsal surface
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? a. Fat b. Fluid c. Flatus d. Hernias
c. Flatus
A nurse in a provider's office is preparing to auscultate and percuss the client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Rhonchi b. Crackles c. Resonance d. Tactile fremitus e. Bronchovesicular sounds
c. Resonance e. Bronchovesicular sounds
A nurse is performing a head and neck examination for an older adult client. which of the following age-related findings should the nurse expect? (Select all that apply.) a. Reddened gums b. Lowered vocal pitch c. Tooth loss d. Glare intolerance e. Thickened eardrums
c. Tooth loss d. Glare intolerance e. Thickened eardrums
A nurse in a providers office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. which of the following findings should the nurse expect? select all that apply a. a concave thoracic spine posteriorly b. an exaggerated lumbar curvature c. a concave lumbar spine posteriorly d. an exaggerated thoracic curvature e. muscles slightly larger on his dominant side
c. a concave lumbar spine posteriorly e. muscles slightly larger on his dominant side
a nurse is caring for a client who reports pain with internal rotation of her right shoulder. This discomfort can affect the client's ability to perform which of the following activities? a. mopping her floors b. brushing the back of her hair c. fastening her bra behind her back d. reaching into a cabinet above her sink
c. fastening her bra behind her back
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) a. Acne b. Warts c. Psoriasis d. Herpes simplex e. Varicella
d. Herpes simplex e. Varicella
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain? b. a client who has incisional pain 72 hr following pacemaker insertion. c. a client who has food poisoning and reports abdominal cramping. d. a client who has episodic back pain following a fall two years ago.
d. a client who has episodic back pain following a fall two years ago.
a nurse is assessing a clients neurosensory system. to evaluate stereognosis. She should ask the client to close his eyes and identify which of the following items. a. a word she whispers 30 cm from his ear b. a number she traces on the palms of his hand c. the vibration of a tuning fork she places on his foot d. familiar object she places in his hand
d. familiar object she places in his hand
