Chp 22 & 31
A nurse is measuring an adult clients tympanic temperature. Which of the following actions should the nurse take?
Insert the probe with a circular motion
While auscultating a clients heart sounds, the nurse heard turbulence between S1 and S2. The nurse should document this finding as which of the following?
A systolic murmur
When preforming an initial assessment on a patient, which piece of information is of highest priority?
Any allergies to medications
When performing an auscultation for heart rate and rhythm (S1 & S2) it is most important to listen:
At the first intercostal space, left midclavicular line, with the diaphragm
When checking blood pressure with an automated machine, if the reading is considerably outside the previous reading for the patient, the nurse should first:
Check the BP in the other arm
When planning care for a patient with a respiratory complaint, which pieces of information are most important to consider?
Decreased appetite Abnormal breathe sounds Decreased activity tolerance
A holistic nursing assessment of a patient is necessary to:
Establish a patient trust in the nurse
A nurse is collecting data about a clients skin turgor. Which of the following actions should the nurse take?
Grasp a fold of skin on the clients forearm or near the sternum
What should the nurse weighing an infant in outpatient clinic so?
Keep one hand hovering over the infant during the weighing process
When preparing a patient for a pelvic examination, you would first position her on the table in the _____ position until the examiner is ready to preform the examination
Lithotomy position
A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
Massaging the clients back Rationale: the gate control theory is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Massaging the clients back is a distraction technique.
A nurse is caring for a client who has recurrent herpes Symplex one type one lesions. The nurse should perform a focused assessment of which of the following areas of the clients body?
Mouth Rationale: herpes simplex type 1 most commonly occurs on the clients mouth
A nurse is reinforcing teaching with the souse of a client about how to take a blood pressure. Which of the following action by the spouse indicates a need for further instruction?
Place the clients arm above the level of the heart Rationale: the spouse needs further instruction by the nurse. To ensure an accurate reading, the clients arm should be placed at the level of the heart
When a nurse obtains and then usually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
Positioning the clients arm above the heart level Rationale: Positioning the clients arm too high, such as on the overhead bed table, can cause erroneously low blood pressure readings. Another possible source is a cup with a bladder that is too wide for the clients arm.
A nurse is checking a clients bowel sounds. At which of the following times should the nurse auscultate the clients abdomen?
Prior to precussing the abdomen Rationale: according to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpitation can stimulate the intestines, increase their motility, and intensify the bowel sounds.
A nurse is collecting data about a clients pulmonary system. While auscultating the clients lungs the nurse hears continuous harsh low pitch sounds over the trachea and bronchi. Which of the following terms should the nurse used to document this finding?
Rhonchi Rationale: Rhonchi are harsh sounds similar to snoring or moaning. Air passing through swelling or obstructions causes these adventitious breathe sounds.
A Spanish speaking client arrives at the triage desk in the ER and states to the nurse "no speak English, need interpreter"
Seek an interpreter from the hospitals interpreter services
Neurologic checks are performed for the patient who has experienced an intracranial injury to determine:
State of cognition Pupil reactions An increase in intracranial pressure
A nurse is counting a clients apical pulse rate. Identify where the nurses should place the stethoscope to auscultate the apical pulse.
The client should auscultate the clients apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercoastal space & below the left nipple line 7.6 cm to the left of the sternum
A nurse is monitoring a clients peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse.
The posterior tibial pulse is located near the inner ankle, behind the medial malleolus
When auscultating the lung sounds, you should:
Turn off music Use the diaphragm of the stethoscope Follow a systematic pattern of the stethoscope placement
A nurse is reinforcing teaching with a client about how to use a patient controlled analgesic (PCA) pump. Which of the following statements should the nurse include in the teaching?
Use the pain scale to determine if you should push the medication self administer button
