Module 1 (215)

A nurse is planning to obtain orthostatic blood pressures from a client who has syncope. In what order should the nurse complete the steps?

1. Place the client in a supine position and allow them to rest is the first step. 2. Take the client's blood pressure in the supine position is the second step. 3. Keep the cuff in place and assist the client to a seated position is the third step. 4. Take the client's blood pressure in a seated position is the fourth step. 5. Assist the client to stand and then obtain their blood pressure is the fifth step.

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply.) A. Electrocardiogram monitor B. Tongue depressor C. Tape measure D. Penlight E. Doppler

B. Tongue depressor C. Tape measure D. Penlight

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? Select all that apply. A. "I still have pain since the surgery last month, but it is getting better." B. "The pain from my car accident 2 months ago will not go away." C. "I have had this pain for 9 months." D. "The pain has been off and on for about a year now." E. "The pain isn't always in the same place."

C. "I have had this pain for 9 months." D. "The pain has been off and on for about a year now." E. "The pain isn't always in the same place."

What is the nurse's purpose for conducting a health assessment with a client? Select all that apply. A. Obtaining objective data. B. Formulating a plan of care C. Collecting subjective data. D. Interpreting findings. E. Implementing a plan of care.

B. Formulating a plan of care D. Interpreting findings. E. Implementing a plan of care. (steps within the nursing process that use the data identified by the health assessment.)

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? Select all that apply. A. Height B. Time of day C. Obesity D. Smoking E. Diuretic medication

B. Time of day C. Obesity D. Smoking E. Diuretic medication

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process? A. "Let me stress the importance of being medication adherent." B. "I'd like to discuss your opinions regarding your plan of care." C. "Let's talk about any health issues you've experienced in the last 12 months." D. "I am expecting to spend time discussing your past medical record."

A. "Let me stress the importance of being medication adherent." (The termination phase of the interview contains a summary of important points such as the need to be medication adherent. Setting expectations is addressed in the introduction phase while expanding the client's story and negotiating a plan of care are completed during the interview's working phase.)

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first? A. Assessment B. Analysis C. Evaluation D. Planning

A. Assessment (The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing the client, and observing the client.)

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus

A. Fasciculation (A client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.)

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do? A. Go back in to complete a physical examination of the skin. B. Ask a colleague who saw the client earlier. C. Review the documented client history. D. Omit this part of the physical examination.

A. Go back in to complete a physical examination of the skin. (It is common to forget part of the physical examination, especially at first. It is not unusual to go back to the client and ask to check one or two of the items that have been overlooked. Omitting this part of the physical examination could lead to missing important clinical data for planning client care. Reviewing the documented client history will not provide objective information about the current status of the client's skin. Asking a colleague who saw the client earlier is not an accurate way to collect information for a physical examination of the skin. The new nurse should not rely on the memory of her colleague alone for this information.)

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply.) A. Goggles B. Gown C. N95 mask D. Surgical cap E. Gloves

A. Goggles B. Gown E. Gloves

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing? A. Implementation B. Evaluation C. Analysis D. Planning

A. Implementation (During the implementation step, the nurse carries out the interventions developed in the plan of care, which will allow the nurse and other members of the health care team to monitor the client's progress. Implementation is when the nurse puts the plan of care into action.)

During an adult client's follow-up visit, the client asks the nurse about the overall goal of Healthy People 2030. What should the nurse include in the response? Select all that apply. A. Improve the health of individuals and communities. B. Increase quality of life. C. Eliminate national health disparities. D. Establish requirements for nursing assessment. E. Create guidelines for healthy lifestyle.

A. Improve the health of individuals and communities. B. Increase quality of life. C. Eliminate national health disparities. E. Create guidelines for healthy lifestyle. (The nurse should include these topics in the response. Healthy People 2030 does not establish requirements for nursing assessment.)

While the nurse is preparing to begin a physical examination of a client, the nurse notes that the bed is in the lowest position, the client is in a side-lying position, the television is on at a loud volume, and the lights are dimmed. How should the nurse proceed with the assessment? Select all that apply. A. Lower the bed when the exam is completed. B. Adjust the bed to a comfortable height. C. Turn off the television. D. Keep the lights dim. E. Ask the client to reposition for the exam, as necessary.

A. Lower the bed when the exam is completed. B. Adjust the bed to a comfortable height. E. Ask the client to reposition for the exam, as necessary. (The nurse should adjust the bed to a comfortable height, ask the patient to reposition for the exam as necessary, and lower the bed when the exam is completed. Before turning off the television, the nurse should first ask the client to lower the volume. This would be considered polite and professionally courteous. Adequate lighting and a quiet environment are ideal for a thorough exam.)

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment? A. Patient rated pain level as being a 5 using the rating scale. B. Patient stated, "pain level not that bad." C. Patient experiencing a moderate amount of pain. D. Patient experiencing mild pain.

A. Patient rated pain level as being a 5 using the rating scale. (The nurse should document the exact pain assessment finding which would be "client rated pain level as being a 5 using the rating scale." The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.)

A nurse is documenting their assessment and documents that the client states, "I have a dry cough every morning when I wake up." Which of the following types of data is the nurse documenting? A. Subjective B. Social determinants of health C. Objective D. Olfactory

A. Subjective (Subjective data includes feelings and concerns from the client's point of view. Subjective data is documented using the client's statements written in quotation marks.)

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings? A. Tachypnea B. Bradypnea C. Apnea D. Hyperventilation

A. Tachypnea (A client who has rapid, shallow breathing at a rate greater than 20/min is experiencing tachypnea. Tachypnea can be caused by fever, fear, or exercise, as well as by client conditions like alkalosis or pneumonia.)

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education? A. "The ideal site to obtain a temperature reading depends on the individual client and the equipment available." B. "When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature." C. When taking an oral temperature reading, the thermometer is placed in the posterior sublingual pocket under the tongue with the patient's lips closed. D. "If taken both in the morning and in the evening, a client's evening oral temperature is generally higher than the morning one."

B. "When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature." (The average oral temperature fluctuates considerably. In the early morning hours, it may fall as low as 36.6° C (97.7° F), and in the late afternoon or evening it may rise as high as 37.5° C (99.5°F). The ideal site to obtain a temperature reading depends on the individual client and the equipment available. By contrast, axillary temperatures are lower than oral temperatures by approximately 1°F. The client should close both lips around the thermometer when taking an oral temperature reading.)

A nurse has performed preoperative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind. I do not want to have this surgery." Which of the following ethical principles is the client using? A. Nonmaleficence B. Autonomy C. Justice D. Fidelity

B. Autonomy (Autonomy involves the client's right to make decisions about their care, including the right to refuse treatment if they choose. This ethical principle refers to a client's freedom.)

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose? A. Identify conditions that the health care provider may have missed. B. Identify in what areas the client needs the most care. C. Identify the client's medical diagnosis. D. Identify in what areas the client can educate the family.

B. Identify in what areas the client needs the most care. (During the overall assessment of the client, the nurse is able to use the findings and decide in which areas the client is in need of the most care. The nurse should not identify conditions that the health care provider may have missed or identify the client's medical diagnosis, as making medical diagnoses is not within the nursing scope of practice. The nurse may provide education to the client's family throughout the client's care; however, the nurse should not delegate education of the family to the client, because this is the nurse's responsibility.)

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment? A. Percussion B. Palpation C. Inspection D. Auscultation

B. Palpation (Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.)

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? A. Unexpected sounds made by tapping on the client's skin B. Skin temperature, moisture, or unexpected findings C. Heart sounds, lung sounds, and bowel sounds D. The client's cleanliness and grooming

B. Skin temperature, moisture, or unexpected findings (The nurse can make judgments about the findings of the skin, underlying tissue, muscle, and bones by using palpation to assess for body temperature, moisture, texture, and other unexpected findings, such as lumps and deformities.)

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? A. Bradycardia B. Tachycardia C. Fasciculation D. Tachypnea

B. Tachycardia (A heart rate of greater than 100/min is considered tachycardia. The nurse should further assess the client for a potential cause, such as anxiety, fever, or pain.)

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate? A. The client has been a chronic smoker for 10 years. B. The client takes a narcotic pain medication for chronic pain. C. The client reports anxiety due to being in the hospital. D. The client has a history of anemia.

B. The client takes a narcotic pain medication for chronic pain. (Some medications for pain, such as narcotics and opioid analgesics, can depress the rate as well as the depth of respirations due to depressing the central nervous system.)

The nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? A. The client is feeling better B. The client's abdomen is soft and nondistended C. The client's status is unchanged D. The client appears in pain

B. The client's abdomen is soft and nondistended The nurse should include factual, accurate, and objective information. This entry reflects the inspection part of the nurse's assessment.

A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do? A. Make sure the arm selected is covered with clothing. B. Position the arm so that it is below waist level. C. Ask the client to sit quietly in a chair for 5 minutes. D. Palpate the radial artery to confirm a pulse is present.

C. Ask the client to sit quietly in a chair for 5 minutes. (To ensure an accurate blood pressure measurement, the nurse should ask the client to sit quietly for at least 5 minutes in a chair. The arm selected for measurement should be free of clothing. The nurse should palpate the brachial artery to confirm that it has a viable pulse. The arm should be positioned at heart level.)

The nurse is preparing to conduct an interview with a hospitalized client. What nursing intervention can best ensure a confidential and comfortable environment for the client? A. Implementing therapeutic communication techniques during the interview. B. Conducting the interview after the client's visitors have left. C. Asking permission to draw the client's privacy curtain. D. Explaining why it is important to take notes during the interview.

C. Asking permission to draw the client's privacy curtain. (In order to support effective communication, the client must feel that the environment is comfortable and the conversation will be confidential. Drawing the privacy curtain is an effective way to project privacy and thus improve the comfort on the environment where the interview will take place. While it is preferable to conduct the interview at a time when visitors are not present, it may not be realistic to wait until the client is alone. Explaining the advantage of notes and using therapeutic communication techniques are associated with effecting good communication but are not directly associated with environment control.)

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? Select all that apply. A. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's radial pulse on the other wrist. C. Assess the client's apical pulse for a full minute. D. Assess the client's S1 and S2 sounds for regularity. E. Question the client about existing cardiac conditions.

C. Assess the client's apical pulse for a full minute. D. Assess the client's S1 and S2 sounds for regularity. (If the radial pulse is irregular or the client's condition calls for a more precise pulse rate, then an apical pulse should be assessed for 1 minute. The examiner places the stethoscope at the apex (fifth intercostal space at the midclavicular line) and auscultates the S1 and S2, noting the rate and rhythm. None of the remaining options would effectively determine the reliability of the original assessment)

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Deduct the client's shoe height from the measurement. B. Have the client gently lift their chin and look toward the ceiling. C. Ensure the client's feet are in contact with the wall or measuring pole. D. Pull up the measuring pole and extend the headpiece after the client steps on the scale.

C. Ensure the client's feet are in contact with the wall or measuring pole. (The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.)

What is a nursing goals for the introductory phase of the nurse-client interview? A. Inviting the client to tell their story. B. Reviewing the client's records. C. Establishing a trusting, respectful rapport with the client. D. Responding therapeutically to the client's emotional cues.

C. Establishing a trusting, respectful rapport with the client. (During the introduction phase of the nurse-client interview, the nursing focus is on putting the client at ease and establishing trust. Actions that the nurse will take during this phase of the interview process include greeting the client, establishing rapport, and establishing the agenda for the interview. Inviting the client's story and responding to emotional cues are actions within the working phase while reviewing the client's records in done in the pre-interview phase.)

A nurse is performing a preadmission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse? A. Asking the client to clarify a statement B. Asking the client open-ended questions C. Maintaining an arm's length between self and client D. Stating name and providing credentials upon entering the client's room

C. Maintaining an arm's length between self and client (The nurse should maintain a personal space of about an arm's length, 46 to 102 cm (18 to 40 in), when communicating with the client. This is a form of nonverbal communication.)

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? A. Fever 101 B. Pulse rate is tachycardic C. Oxygen saturation 96% on oxygen 2 L/min via nasal cannula D. Blood pressure 108/65 mm Hg

C. Oxygen saturation 96% on oxygen 2 L/min via nasal cannula (The nurse should record the percentage of the client's oxygen saturation and indicate whether the client is on room air or is receiving oxygen. If the client is on oxygen, the nurse should record the type of the device and the rate at which oxygen is being delivered.)

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? A. Use the soft end of a cotton swab over the client's abdomen B. Auscultate the tender areas of the client's abdomen through clothing C. Palpate the tender areas of the client's abdomen last. D. Use deep palpation when assessing the client's abdomen.

C. Palpate the tender areas of the client's abdomen last. (The nurse should palpate the reported tender areas of the abdomen last to avoid client discomfort throughout the rest of the examination. When assessing the abdomen, the nurse should inspect and auscultate prior to palpation to avoid altering the bowel sounds.)

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possibly interfering with obtaining a pulse oximetry reading? A. Hypertension B. Fever C. Recent scan with contrast dye D. Thin, brittle nails

C. Recent scan with contrast dye (A nurse might have difficulty obtaining a pulse oximetry reading from a client who has recently undergone testing that involves an injection of a contrast dye into the circulatory system. The dye can alter the transmission of the LED light used by the pulse oximetry sensor.)

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client? A. Tell the client that everything will be just fine. B. Change the subject while the client is discussing their feelings. C. Show interest in the client's feelings by acknowledging that they are upset. D. Tell the client that it is wrong to be crying over this situation.

C. Show interest in the client's feelings by acknowledging that they are upset. (When the nurse expresses empathy, the nurse reflects an understanding of the client's feelings and feels the importance of the client's communication. This is a therapeutic communication technique.)

A nurse in the community is completing a manual blood pressure assessment. Which action should the nurse take to ensure the assessment is accurate? A. Ask the client to take deep breaths. B. Ensure that the client is sitting. C. Turn down the television volume. D. Turn down the lights in the room.

C. Turn down the television volume. (When completing a manual blood pressure assessment, it is important to ensure external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure. Turning down the lights in the room will prevent the nurse from being able to read the blood pressure accurately. The client's position will not affect the accuracy of the blood pressure reading. Asking the client to take deep breaths will promote relaxation; however, it will not assist in ensuring accuracy of the assessment.)

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms? A. pertinent positive and negative questions to determine relevant details B. specific questions to secure a description of every symptom C. open-ended questions to allow full freedom of response D. yes-or-no questions to determine relevant areas of the physical examination

C. open-ended questions to allow full freedom of response (Open-ended questions such as "How can I help you?" should be asked by the nurse first to allow full freedom of response. Specific questions are then used to get the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and negatives, are used to retrieve information from the review of systems assessment.)

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks? A. "Can you remember when you first started to feel dizzy?" B. "Have you ever been dizzy enough to fall?" C. "Do you often feel dizzy?" D. "What do you mean by a little dizzy'?"

D. "What do you mean by a little dizzy'?" (Listening and understanding a client is key to discovering a client's needs. As more details are acquired and collated, actual health risks emerge. The nurse should first clarify what the client means by the statement. If is only then that the nurse can determine is a health risk exists. While knowing the details of when the symptom started, how often it occurs, and if falling has occurred is important, clarification of what the client means is the initial focus of the nurse.)

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? A. Close the examination room door but do not pull the curtain in the examination room. B. Remain in the client's room while the client is getting undressed. C. Ask the client if they would like to empty their bladder and bowel before the physical examination begins. D. Do not expose any more of the client's body than required at a time.

D. Do not expose any more of the client's body than required at a time. (The nurse should provide physical privacy by only exposing the section of the client's body necessary at the time for proper assessment. This action helps the client feel less vulnerable.)

A nurse is preparing to conduct a general survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? A. Have an informal conversation with the client before beginning the observation of the client. B. Complete all focused assessments prior to formulating thoughts regarding the client's general health status. C. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible. D. Engage in active listening with the client and allow the client to express concerns early in the assessment process.

D. Engage in active listening with the client and allow the client to express concerns early in the assessment process. (The nurse should engage in verbal communication that involves actively listening to the client. The nurse should keep interruptions to emergencies and provide their full attention to the client, to establish trust.)

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment? A. Palpation B. Percussion C. Auscultation D. Inspection

D. Inspection (Using the nursing process, the nurse should first inspect the client's abdomen and assess for symmetry between the right and left side of the body. The nurse should note the presence of contours and any unexpected findings.)

As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon? A. Spiritual B. Interpersonal C. Physical D. Mental

D. Mental (The client is demonstrating confusion related to time and place. A change in level of consciousness or confusion would be categorized as an alteration in the client's mental status and would require further assessment. Such confusion would not be categorized as being a physical, spiritual, or interpersonal change in the client's health status.)

A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client? A. Axillary B. Temporal C. Tympanic D. Rectal

D. Rectal (Rectal temperatures are considered the most accurate method for obtaining a client's core body temperature.)

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process? A. Enlist the aid of the client's school-age child to interpret for the nurse and the client. B. Ask the client's best friend to interpret for the nurse and client. C. Use jokes and laughter to make the client feel more at ease. D. Request assistance from an interpreter during the assessment.

D. Request assistance from an interpreter during the assessment. (The nurse should enlist a professional interpreter if the client speaks a different language than the nurse.)

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment? A. Tongue depressor B. Penlight C. Reflex hammer D. Stethoscope

D. Stethoscope (The nurse will need a stethoscope to auscultate the sounds of the client's body.)

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following findings should the nurse record as an unexpected finding? A. The client is sitting in a relaxed posture. B. The client is cooperative in answering the nurse's questions. C. The client tells the nurse that visits from their friends and family make them smile. D. The client reports they feel sad and lonely most of the time.

D. The client reports they feel sad and lonely most of the time. (The nurse should record this statement as an unexpected finding.)

The nurse is having difficulty visualizing the apical impulse during a physical examination of the cardiovascular system. Which assessment tool is required for a more accurate assessment? A. tape measure B. cup of water C. stethoscope D. penlight

D. penlight (A penlight provides tangential lighting and is optimal for inspecting structures such as the jugular venous pulse, thyroid gland, and apical impulse of the heart. It casts light across body surfaces that shows contours, elevations, and depressions, whether moving or stationary, into sharper relief.)

When conducting a general survey of a client, the nurse should assess : _______ , _________ , __________ .

level of consciousness, speech, and gait.

During an interview, the nurse remains silent and nods the head periodically while the client is talking. The therapeutic communication technique the nurse is using would be: A. Continuers B. Reflection C. Validation D. Summarization

A. Continuers (The nurse who uses gestures, posture, silence, and head nodding is using cues for the client to continue or continuers. Reflection is repeating the client's last words to encourage the client to express both factual details and feelings. Validation is a way to make a client feel affirmed to acknowledge the legitimacy of an emotional experience. Summarization is providing a review of the client's story during the interview.)

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? Select all that apply. A. Height and weight B. Use of assistive devices C. Past medical history D. Behavior and mood E. Current medication list

A. Height and weight B. Use of assistive devices D. Behavior and mood

A client diagnosed with deep vein thrombosis (DVT) complains of pain in the lower right calf muscle which worsens with walking. The nurse realizes that the client is most likely experiencing which type of pain? A. Idiopathic B. Psychogenic C. Somatic D. Neuropathic

C. Somatic