Practice questions

A charge nurse is reviewing the steps of the nursing process with a student nurse. Which of the following is objective data? a. Respiratory rate 22/min with even, unlabored breathing. b. The client's pain rating id 3 out of 10. c. The client's skin is pink, warm, and dry. d. The UAP reports that the client walked with a limp e. The client reports vomiting.

A, C

A nurse is performing a head and neck assessment examination on an older adult client. Which of the following age-related findings should the nurse expect? a. Reddened gums b. Lowered vocal pitch c. Tooth loss and gum disease d. Glare intolerance to lights e. Thickened tympanic membranes

A, C, D, E

A nursing instructor is teaching nursing students proper techniques of assessment of the heart and neck vessels. The nursing instructor determines understanding when the students state which of the following? Select all that apply. a. Palpate the carotid arteries one at a time. b. Palpate the carotid arteries before auscultating them. c. Auscultate for a pulse rate deficit if the heart rhythm is irregular. d. Place the client in a left lateral position when palpating apical pulsation. e. Palpate the carotid pulse when auscultating the heart for abnormal heart sounds.

A,B,C

A nurse is providing care to an 86-year-old client. The nurse identifies which of the following finding(s) as a normal age-related head and neck change? Select all that apply. a. decreased range of motion of the neck b. cervical curvature of the spine c. decreased temporal pulse d. lumbar stiffness e. smooth thyroid

A,B,D

A nurse is assessing a client's thyroid gland as part of the physical assessment. Which of the following findings should the nurse expect? 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 water e. Finding the thyroid midline on the neck

A,B,E

The nurse prepares material about oropharyngeal cancer for a community health fair. What should the nurse include as actions to prevent the development of this disease? Select all that apply. a. Avoid smoking b. Limit sun exposure c. Practice daily oral hygiene d. Avold excessive alcohol use e. Eat fresh fruits and vegetables

A,C,D,E

A nurse is performing an integumentary assessment on a group of clients. Which of the following findings require immediate intervention by the nurse? a. Pallor b. Cyanosis c. Jaundice d. Erythema

B

A nurse performs a comprehensive assessment on a new client. The nurse observes the following findings: bilateral lower extremities are cool to touch with sparse hair distribution, legs blanch when raised, and client reports leg pain when walking long distances that resolves with rest. The nurse determines these are signs and symptoms of which of the follo disorders? a. venous insufficlency b. arterial insufficiency c. Raynaud's disease d. lymphedema

B

A nurse is assessing post-operative circulation on the lower extremities of a client who had knee replacement surgery. The nurse should test which of the following? a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature

B, C, E

During a cardiovascular exam, a nurse places the diaphragm of the stethoscope at the left mid-clavicular line, 5th intercostal space. Which of the following data is the nurse attempting to auscultate? a. Ventricular gallop b. Closure of the mitral valve C. Closure of the pulmonic valve d. Apical heart rate e. Murmur

B, D

While completing the past history of a client's peripheral vascular and lymphatic systems, the nurse is concerned that the client is at risk for peripheral vascular disorders. What assessment data would cause the nurse to arrive at this conclusion? (Select all that apply.) a. Heart attack 5 years ago b. Blood pressure 178/90 mm Hg c. Currently smokes one pack per day d. Body mass index 30 e. Mother diagnosed with diabetes at age 70

B,C,D

What are the functions of the lymphatic system? (Mark all that apply.) a, Maintaining protein balance b. Draining lymph from the bloodstream c. Fighting infection d. Hydrating the thymus e. Maintaining fluid balance

B,C,D,E

What are the components of S1? (Mark all that apply.) a. An earlier aortic sound b. An earlier mitral sound c. A later pulmonic sound d. A later tricuspid sound e. An earlier tricuspid sound

B,D

The nurse is reviewing dietary changes for a client with hypertension in order to manage the condition. What should the nurse include in the teaching? Select all that apply. a. Consume 2,300 mg sodium per day. b. Use alcohol in moderation. c. Have a dietary intake of more than 3,500 mg of potassium per day. d. Include more fruits and vegetables in meals. e. Use low-fat dairy products with reduced saturated and total fat.

B,D,E

A nurse is wearing sterile gloves in preparation to perform a sterile procedure. Which of the following objects can the nurse touch without breaking sterile technique? a. A bottle containing sterile solution. b. The edge of the drape at the base of the field. c. The inner wrapping of an item on the sterile field. d. An irrigation syringe on the sterile field. e. One gloved hand with the other.

C,D,E

While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. a. Irregular border b. Deep C. Circular in shape d. Moderate leg edema e. Client report of severe pain

C,E

Fine to coarse bubbly sounds

Crackles

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that don't require a provider's order. Which of the following would be included? a. Writing a RX for morphine sulfate for pain as needed. b. Inserting a nasogastric tube to relieve gastric distention. c. Showing a client how to use an incentive spirometer. d. Repositioning a client every 2 hours to prevent skin breakdown. е. Teaching a client how to perform ROM exercises.

D, C, E

True or False: Bone conduction is longer than air conduction.

False

Intermittent claudication, Diminished or absent pulses, Dependent rubor, Circular shaped ulcers,Skin cool to touch

PAD

Aching, cramping pain, Pulses present, Irregular shaped ulcers, Leg edema, Thickened skin

PVD

Dry, grating rubbing sounds

Pleural friction Rub

Low, breezy sounds

Vesicular

High pitched whistling sounds

Wheezes