test 2 review part 1
The patient can follow directions but cannot pronounce words to express needs or thoughts. Which term will the nurse use to document this assessment finding? a. Expressive aphasia b. Receptive aphasia c. Primary dysphagia d. Vocal dysphagia
a
The patient has red, itchy eyes with thick yellow drainage. What will the nurse plan to do as a result of this assessment finding? a. Apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient. b. Assess the patient's visual fields and compare results from each of the patient's eyes. c. Ask the patient about any history of hyperthyroid disease, hypertension, or Addison's disease. d. Instruct the patient not to pluck or wax the eyebrows until the eye infection symptoms have resolved completely.
a
The nurse hears a distinctive swooshing sound with each heartbeat when auscultating the patient's heart sounds. What is the cause of this assessment finding? a. The mitral valve is leaking and some blood leaks backward with each heartbeat. b. The nurse's stethoscope is not placed firmly enough against the patient's skin. c. The patient's tricuspid valve was replaced with a mechanical prosthetic valve. d. The patient is having short runs of premature supraventricular contractions.
a
The nurse is assessing a patient with suspicious bruises. Which action is most appropriate to facilitate an accurate account of the patient's injuries? a. Ask the patient's family member to wait outside in the waiting room. b. Ignore the bruises because the patient has provided an explanation. c. Realize that the patient may be abused, but that is a family issue. d. Provide referrals for health counseling once the assessment is complete.
a
The nurse is caring for a patient who feels the urge to urinate but is unable to void. Which is the appropriate action of the nurse? a. Scan the patient's bladder to see how much urine is present. b. Obtain a urine sample for urinalysis, culture, and sensitivity. c. Perform a focused physical assessment of the patient's perineum. d. Help the patient to utilize absorbent undergarments for protection.
a
The nurse is caring for a patient who was pulled unconscious from the pool after a near drowning. Which lung sounds will the nurse expect to hear upon auscultation? a. Moist crackles b. Expiratory wheezes c. Friction rub d. Coarse rhonchi
a
The nurse is discontinuing the patient's indwelling urinary catheter. The catheter is not easily withdrawn after the balloon is deflated. Which is the appropriate nursing action? a. Reattach the syringe and attempt to withdraw more water from the balloon. b. Ask the patient to bear down as the catheter is withdrawn with gentle pressure. c. Review the patient's chart to see how much water was inserted into the balloon. d. Explain to the patient that removal of the catheter may cause significant discomfort.
a
The nurse notes that the patient has hyperactive bowel sounds in all four quadrants of the abdomen. Which factor from the patient's history will account for this assessment finding? a. The patient has had gastroenteritis for the last 4 days with watery diarrhea. b. The patient takes iron supplements daily to treat chronic anemia. c. The patient has a paralytic ileus after undergoing abdominal surgery. d. The patient takes ibuprofen 3 times daily for arthritis pain.
a
The patient becomes acutely short of breath when lying flat in bed. Which term will the nurse use to document this assessment finding? a. Orthopnea b. Atelectasis c. Emphysema d. Stridor
a
The patient knocked over the specimen container and spilled some of the urine that had been collected for a 24-hour urine analysis. Which is the appropriate action of the nurse? a. Start the collection over again with a new container. b. Inform the patient that the test will have to be canceled c. Replace the lid on the container and continue the collection. d. Extend the collection period by 2 hours for a replacement void.
a
The patient's urinalysis indicates small amounts of protein in the urine. Which diagnosis does the nurse anticipate to see in the patient's electronic health record? a. Diabetes mellitus b. Diabetes insipidus c. Hypothyroid disease d. Hyperparathyroid disease
a
Which assessment finding is expected for a patient presenting with a middle ear infection? a. The right tympanic membrane is pink and bulging. b. The patient becomes dizzy when sitting upright. c. The pinna is red, swollen, and tender to palpation. d. The eardrum is a translucent pearly gray color.
a
Which assessment finding will the nurse expect to note during physical examination of the patient with a history of uncontrolled hyperthyroid disease? a. Exophthalmos b. Strabismus c. Entropion d. Diplopia
a
Which assessment findings lead the nurse to suspect that the patient has a history of alcohol abuse? a. The patient has prominent tiny blood vessels running across the face. b. The patient's skin is abnormally dry and flaky, especially on the legs. c. The patient's nails have splinter hemorrhages along the nail bed. d. The patient's breath smells faintly of fruity chewing gum.
a
Which factor in the female patient's history places her at higher risk for the development of breast cancer? a. The patient's first period started at age 10. b. The patient has three children under the age of 12. c. The patient used condoms exclusively for contraception. d. The patient's breasts are tender before each period.
a
Which outcome is appropriate for the patient with risk for urinary tract infection related to recent urinary catheterization? a. The patient's urine will remain free from white blood cells and bacteria. b. The patient will take prescribed antibiotics until the urinary symptoms are gone. c. The patient will have serial urine cultures to ensure that the infection is resolved. d. The patient will carefully wipe the perineal area from front to back after voiding.
a
Which question is best suited for determining the patient's chief complaint? a. "What brings you to the hospital today?" b. "How long have you been having chest pain?" c. "Did your doctor tell you to come to the hospital?" d. "Have you ever experienced this problem before?"
a
Which technique will the nurse use to facilitate the history and physical examination of a small child? a. Examine the child's hands and feet before listening to breath sounds. b. Direct assessment questions to the child to avoid unwanted parental influence. c. Gently palpate the child's abdomen before auscultating for bowel sounds. d. Call the parents by their first names to establish a more trusting bond
a
Which characteristics helped promote the development of the patient's tortuous varicose veins (Select all that apply.) a. Smoking 2 packs of cigarettes daily for the last 15 years b. Frequently sitting with the legs crossed c. Taking naproxen sodium daily for arthritis pain d. Standing for long periods of time at work e. Eating a gluten-free, low-sodium diet for the last 10 years
a,b,d
Which assessment findings show that the patient has a history of chronic arterial insufficiency in the legs? (Select all that apply.) a. The nurse must use a Doppler to find the patient's pedal pulses. b. The patient has calf pain when the knee is flexed and foot pointed downward. c. The patient's legs are cool to the touch and show no hair growth. d. The patient has 3+ pitting pedal edema extending up to the knees. e. The patient has tortuous varicose veins from the hip to the ankle
a,c
Which positions may be used to perform a rectal examination on the patient? (Select all that apply.) a. Sim's b. Supine c. Lithotomy d. Lateral recumbent e. Dorsal recumbent
a,c
Which assessment findings lead the nurse to conclude that the patient has had chronic obstructive pulmonary disease (COPD) for many years? (Select all that apply.) a. The patient's nails have a clubbed shape. b. The patient has splinter hemorrhages under the nails. c. The patient's chest appears rounded and bulging. d. The patient is short of breath with minimal activity. e. The patient has soft, spongy gums that bleed easily
a,c,d
The nurse hears a blowing sound when auscultating the patient's carotid artery. What is the appropriate action of the nurse? a. Notify the health care provider immediately as the patient may be having a stroke. b. Gently feel over the patient's carotid artery to check for a faint vibration. c. Massage the patient's carotid artery to determine if the blowing sound subsides. d. Palpate the patient's carotid pulse while the patient's neck is hyperextended.
b
The nurse is caring for a patient who has a dangerously low platelet count. Which assessment finding will the nurse expect to note during physical examination of the patient? a. Bright yellow jaundice in the sclera of the patient's eyes b. Pinpoint red spots on the skin of the patient's torso c. Dry, flaky skin with evidence of frequent scratching d. Thick indurated skin across the patient's back
b
The nurse is caring for an incontinent male patient with a large sacral pressure injury. Which is the safest intervention that will maintain skin integrity and facilitate healing of the ulcer? a. Obtain a surgical consult for placement of a suprapubic urinary catheter. b. Apply a condom catheter attached to a bedside urinary drainage bag. c. Insert an indwelling urinary catheter attached to a small volume drainage bag. d. Perform intermittent straight catheterization of the patient every 4 to 6 hours.
b
The nurse is conducting a health history for a patient who does not speak English. What is the best action of the nurse? a. Communicate with the patient using simple gestures and drawings. b. Arrange for a medical translator to be present during the health history interview. c. Ask an English-speaking family member to translate the nurse's questions. d. Obtain the patient's health history from an English-speaking family member.
b
The nurse notes that the patient has bilateral entropion. What will the nurse plan to do as a result of this assessment finding? a. Instruct the patient to rinse the mouth gently with warm saline solution. b. Clean the patient's eyelids gently and apply antibiotic ointment. c. Place a wedge pillow between the patient's legs to prevent crossing at the hip. d. Elevate the head of the patient's bed and administer supplemental oxygen
b
The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in place. Which is the priority action of the nurse? a. Measure the patient's urinary output. b. Ensure that the catheter tubing is not kinked. c. Provide perineal care to the patient for comfort. d. Reassure the patient that the sensation is to be expected.
b
The patient's urinalysis indicates increased specific gravity of the urine. Which finding does the nurse anticipate will be found upon assessment? a. The patient uses supplemental oxygen due to COPD. b. The patient is thirsty with dry oral mucus membranes. c. The patient has a history of benign prostatic enlargement. d. The patient just completed antibiotics for a bladder infection
b
Which assessment finding explains the cause of the patient's stress urinary incontinence? a. The patient uses a wheelchair and cannot get to the toilet in time to void. b. The patient gave birth to six babies who weighed more than 9 pounds. c. The patient suffered a spinal cord injury and has no sensation below the waist. d. The patient self-catheterizes due to urinary retention from multiple sclerosis.
b
Which assessment finding leads the nurse to question an order for an abdominal flat plate test? a. The patient is very claustrophobic. b. The patient is 8 weeks pregnant. c. The patient has a history of renal failure. d. The patient is allergic to iodine and shrimp
b
Which assessment finding supports the nursing diagnosis overflow urinary incontinence related to urethral obstruction? a. Advanced dementia prevents the patient from indicating need to urinate b. Post void residual of 900 mL after incontinence of small amounts of urine c. Leakage of urine around the urostomy appliance leading to skin irritation d. Incontinence of large amounts of urine every time the patient coughs or sneezes
b
Which is the appropriate method to obtain a urinalysis specimen for culture and sensitivity from an incontinent female patient? a. Obtain a midstream specimen. b. Perform straight catheterization. c. Obtain a double-voided specimen. d. Leave a fresh bedpan under the patient.
b
Which technique can the nurse use to facilitate assessment of the thyroid gland? a. Have the patient tip the head back and cough twice. b. Watch the patient's neck when sipping water from a straw. c. Have the patient slowly turn the head from side to side. d. Gently palpate from underneath the jaw to behind the ear.
b
Which technique will the nurse use to assess the patient's olfactory nerve? a. Ask to shrug the shoulders and turn the head against the nurse's hand. b. Ask the patient to identify the smell of peppermint oil and orange peel. c. Ask the patient to read the smallest set of letters on a Snellen eye chart. d. Ask the patient to stick out the tongue and move it side to side from midline.
b
While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. Which term will the nurse use to document this assessment finding? a. Crackles b. Rhonchi c. Wheezes d. Friction rub
b
Why does the nurse utilize a head-to-toe approach when performing physical examinations of patients? a. The head-to-toe format excludes unnecessary body systems. b. It is a methodical way to include all body systems. c. It reduces time by allowing examination of only one side. d. It requires that painful procedures be done first.
b
How can the nurse most accurately assess the skin tone for an older adult African American patient with deeply pigmented skin? a. Utilize fluorescent lighting. b. Turn up the heat in the room. c. Utilize natural sunlight. d. Turn down the temperature in the room.
c
The nurse is caring for a dehydrated, confused patient whose breath smells like fruity bubble gum. What is the priority action of the nurse based on these assessment findings? a. Check the patient's pulse oximetry. b. Check the patient's oral mucosa for thrush. c. Check the patient's blood sugar. d. Check the patient's sclerae for jaundice
c
The nurse is inserting an indwelling urinary catheter before the patient has abdominal surgery. Which type of catheter will the nurse utilize for the procedure? a. Straight catheter b. Single-lumen catheter c. Double-lumen catheter d. Triple-lumen catheter
c
The nurse is performing urinary catheterization for a female patient. The catheter will not advance any further but there is no urine output. What is the appropriate action of the nurse? a. Withdraw the catheter and notify the health care provider immediately. b. Palpate the patient's bladder to assess for fullness, tenderness, or distention. c. Leave the catheter in place and reattempt insertion with a new sterile catheter. d. Utilize the bladder scanner to determine how much urine is in the patient's bladder.
c
The patient has been smoking 2 packs of cigarettes for the last 15 years. How will the nurse chart the patient's tobacco use history in pack-years? a. 7.5 pack-years b. 17 pack-years c. 30 pack-years d. 35 pack-years
c
The patient is brought in after collapsing outside on a very hot day. Which assessment finding will the nurse expect to note during physical examination of the patient? a. Pallor of the patient's extremities b. Cyanosis of the patient's nail beds and lips c. Dry mucus membranes and poor skin turgor d. Lower extremity edema and a generalized itchy rash
c
The patient's pupils are the size of tiny pinpoints. Which factor could lead to this assessment finding? a. The patient has been taking high doses of steroids. b. The patient suffered massive head trauma and is brain dead. c. The patient injected heroin intravenously 1 hour ago. d. The patient has developed acute narrow angle glaucoma.
c
When is the best time for a male patient to perform a testicular self-assessment? a. Before getting out of bed in the morning b. After having a bowel movement c. After getting out of a hot tub d. Immediately following ejaculation
c
Which assessment finding is expected for a patient who may have a lower extremity deep vein thrombosis (DVT)? a. Deep burning pain in the extremity that worsens with walking and exercise b. Weak pedal pulses and an absence of hair on the affected extremity c. Calf pain when the knee is flexed slightly and the foot is pointed downward d. Numbness and tingling of the extremity with hyperreactive reflexes
c
Which assessment finding needs to be communicated promptly to the patient's health care provider? a. Post void residual of 15 mL of urine. b. Leakage of small amounts of urine when coughing. c. Urine output of 160 mL over the last 8 hours. d. Patient's report of an urge to void during palpation of the bladder
c
Which assessment finding will the nurse expect to note during physical examination of the patient with a cast on the lower left leg? a. The patient's left foot has a musty, fetid smell b. The patient's left foot has 3+ pitting edema and pallor. c. The temperature of the left foot is the same as the right foot. d. The patient's left foot is cool with thin, shiny skin.
c
Which intervention will facilitate the physical examination of a patient with mobility issues? a. Be sure that the head of the examination table may be elevated for the patient's comfort. b. Tune the radio to the nurse's favorite station as a relaxation intervention for the patient. c. Make sure that the patient has sufficient space and assistance to transfer onto the examination table. d. Instruct the patient on the safest way to transfer onto the examination table.
c
Which test can the nurse use to assess the patient's balance? a. Have the patient reach out to touch the nurse's finger then the patient's nose. b. Have the patient track the nurse's finger as it moves through the field of vision. c. Have the patient stand with feet together, arms out, and eyes closed. d. Have the patient run the heel of the foot along the shin of the other leg.
c
The family requests insertion of a Foley catheter to address the elderly patient's frequent episodes of incontinence. Which is the best action of the nurse? a. Obtain an order for an indwelling urinary catheter. b. Teach family to perform intermittent straight catheterization. c. Utilize disposable absorbent undergarments for the patient. d. Implement a bladder training program to promote continence. ANS: D
d
The home care nurse is caring for a patient with an indwelling urinary catheter after spinal cord injury. The catheter is patent with clear yellow urine after being in place for 8 weeks. Which is the appropriate action of the nurse? a. Request an order for a urinalysis with culture and sensitivity. b. Irrigate the patient's catheter using 60 mL of sterile normal saline. c. Remove the catheter immediately and notify the health care provider. d. Contact the health care provider for an order to change the catheter
d
The mother of a small infant is surprised when the clinic scale indicates a 1-pound weight gain from the scale used that morning at home. What is the appropriate response of the nurse? a. "Babies have significantly different weights throughout the day." b. "Variations occur because of the weight of the baby's clothing." c. "Weight variation of 1 to 2 pounds is common for most scales." d. "Weight measurements can vary with different scales."
d
The nurse is caring for a patient who develops slurred speech with right-sided facial drooping. The patient is also unable to make a fist with the right hand. What is the priority action of the nurse? a. Place a cool washcloth on the patient's forehead and turn down the lights. b. Obtain an order from the provider for a consultation with a speech therapist. c. Feed the patient by placing the food on the unaffected side of the mouth. d. Immediately obtain vital signs and notify the hospital's acute stroke team.
d
The patient comes to the hospital with a variety of symptoms. Which symptom will the nurse assess first? a. The patient experiences joint stiffness after sitting still for long periods of time. b. The patient developed an itchy rash after taking the second dose of antibiotics. c. The patient is nauseated and vomited a small amount earlier this morning. d. The patient feels short of breath and has audible expiratory wheezes.
d
The patient has cloudy yellow urine with a faint odor of ammonia. Which laboratory test will the nurse expect to note in the patient's admission orders? a. Serum albumin and pre-albumin b. Serum calcium and magnesium levels c. Fasting blood sugar every morning d. Urine sample for culture and sensitivity
d
The patient presents with fever for the last few days, sore throat, and enlarged lymph nodes under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes? a. "Enlarged lymph nodes are associated with hypertensive heart disease." b. "You probably have a blockage in the thoracic lymph duct." c. "You should probably see an oncologist to rule out lymphedema." d. "They are most likely enlarged as a result of the throat infection
d
Which question will the nurse ask the patient to assess abstract thinking ability? a. "Can you tell me the color of the blanket on your bed?" b. "Can you tell me what you ate for breakfast this morning?" c. "Can you tell me about what it was like to grow up in your neighborhood?" d. "What do I mean when I say that something costs an arm and a leg?" ANS: D
d
Which teaching will the nurse provide to the patient before having an intravenous pyelogram (IVP)? a. Drink water and do not void so the bladder will be full during the test. b. An urge to void may be felt as the endoscope passes through the urethra. c. The urine may have an orange or pink for a day or two following the test. d. Drink plenty of water afterward to prevent kidney damage from the contrast dye.
d
Which term will the nurse use to document the patient's drooping right eyelid? a. Ectropion b. Esotropia c. Photophobia d. Ptosis
d