Health Assessment week 2
a nurse is caring for a client who has a PICC line. the nurse should identify that which of the following information is true about this type of IV route?
A PICC line is a long catheter inserted through the veins of the antecubital fossa.
a nurse is assessing a client who is dark-skinned. In which of the following areas of the client' body should the nurse assess the client for adequate oxygenation? (select all that apply)
nail beds oral mucosa lips
a nurses is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestation should the nurse expect during hyperventilation? (select all that apply)
numbness and tingling of extremities lightheadedness chest pain
a nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?
pale mucosa
which of the following terms indicates that a medication is given via an injection?
parenteral
a nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (Select all that apply)
"Have you had trouble hearing?" "Do you ever lose your balance?" "Have you ever used hearing aids?" "Do you have ringing in your ears?"
a nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (select all that apply)
"Smoking is linked to various forms of cancer" "It might take several attempts to finally stop smoking" "There are pharmacologic therapies that can help a person stop smoking"
a charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of teaching?
"clubbing of the fingers indicates a chronic state of impaired perfusion."
A nurse is caring for a client who is in early stage renal failure and has a prescription for the infusion of IV fluids. Which of the following IV fluids does the nurse anticipate a prescription for and why?
0.45% sodium chloride because it dilutes extracellular fluid and rehydrates the cell.
a nurse administers the first dose of a client's prescribed antibiotic via intermittent IV bolus. During the first 10-15 min of administration, which of the following assessments is the nurse priority?
Assess the client for a systemic allergic reaction.
a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following description should the nurse use to describe a pleural friction rub? (select all that apply)
Coarse grating tone Heard on inspiration and expiration Pain with breathing
Which of the following actions should a nurse take when converting an IV infusion to a saline lock?
Flush the IV catheter to confirm patency
a nurse is preparing to administer an intradermal injection. Which of the following actions should the nurse take to ensure proper technique?
Use a tuberculin syringe with a 5/8-inch, 25 gauge needle.
a nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
elevate the head of the client's bed.
a nurse is performing a head and neck assessment on a client. The client reports a high pitched ringing in their ears. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?
encounter
prior to entering the surgical-scrub area, which of the following PPE items should a nurse don? (select all that apply)
gown, protective eyewear hair cover mask shoe cover
when opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack?
holding the sterile pack below waist or table level.
A nurse is caring for a client who was admitted to the hospital for the same day surgery and has a new prescription for continuous IV therapy. Which of the following actions should the nurse take when administering the IV therapy?
inspect the IV solution for fluid color, clarity, and expiration date.
A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries made by the newly licensed nurse is an example of correct documentation?
inspiratory wheeze auscultated at the left lateral chest.
a nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take?
keep the client's bed in the lowest position.
a nurse is caring for a client who had a suspected stroke. Which of the following actions should the nurse take? (select all that apply)
make client NPO assess the client's orientation obtain the client's VS
A nurse is removing a client's IV catheter. Which of the following actions should the nurse take?
pull the catheter straight back from the insertion site.
a nurse is performing a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading the fine print. In which of the following sections of the client's EHR should the nurse document this finding?
review of systems
a nurse should identify that which of the following areas of the hands requires special attention during the prescrub wash?
the area under the fingernails
a nurse in the emergency department is assessing a client who has experienced thoracic trauma from a MVA. Which of the following is an indication of a pneumothorax?
the client is experiencing unequal movement of the posterior chest.
while waiting for a sterile procedure to begin, how should a nurse position their hands and arms?
with hands clasped together in front of the body above waist level.
a nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect?
yellow sclera
a nurse is assessing a client who has a lump on their neck. Which of the following should the nurse ask the client? (select all that apply)
"are you experiencing difficulty breathing?" "how long has the lump been on your neck?" "is the lump causing you discomfort?" "are you having difficulty swallowing?"
a nursing is providing teaching to an assistive personnel (AP) about the use of sterile gloves? Which of the following instructions regarding the open-gloving method should the nurse give?
"grasp only the inside of the glove with your ungloved hand."
a nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make?
"you should make every effort to receive a flu every year."
A client is the receive a 1,000 mL bag of 5% dextrose in LR over 8 hours. Using the tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
31 gtt/min
a nurse is preparing to administer ceftriaxone 1 g in mL IV over 30 min. The drip rate is 10 gtt/mL. The nurse should set the infusion rate to administer how many gtt/min?
33 gtt/min
a nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field? (select all that apply)
A cotton ball dampened with sterile normal saline is placed on the field The nurse turns to address the client's question concerning the procedure The procedure is postponed for 30 min to accommodate the client A liquid is poured into a sterile container from a distance of 25 cm (10 in)
A nurse is discontinuing a peripheral IV catheter. Upon removal, the nurse should assess the catheter for which of the following?
An intact catheter tip.
A nurse is caring for a client who is receiving 0.9 NS IV and 75mL/hr through a triple lumen central venous access device. The IV pump alarm sounds, indicating that there is an occlusion. Which of the following actions should the nurse take first?
Check the line at or above the hub for a kinked tubing that is creating a resistance to flow.
A nurse is assessing a client who is receiving 0.9% NS IV at 125ml/HR. Which of the following should the nurse recognize as a possible complication related to the IV therapy?
Client reports coughing and SOB
A nurse has just initiated an IV infusion and is teaching the client about possible complications. The nurse should include that which of the following findings is an indication of early infiltration?
Coolness
A nurse assesses a client's IV insertion site and finds that it is red, warm, and slightly edematous. Which of the following actions should the nurse take?
Discontinue IV line
A nurse has just initiated a new PIV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing?
Every 96 hours.
a nurse is preparing to administer an IV medication to a client. The nurse should identify that which of the following is a disadvantage of administering IV medications?
IV medications are irreversible
a nurse is assessing a client's head. which of the following should the nurse identify as an unexpected findings? (select all that apply)
Oval white patches in the client's hair A lesion on the client's scalp Protrusion of the client's head Edema around the client's eyes
a nurse is admitting a client who has a new diagnosis of COPD. Which of the following information documented by the nurse is subjective data? (select all that apply)
Report from client says they sleep while propped on two pillows at night Client says they quit smoking 2 years ago Client states, "Being short of breath all of the time is making me depressed"
A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (select all that apply)
The client is sitting in a tripod position The client is using pursed lipped breathing The client appears confused
A nurse is caring for a client who is receiving D5 water with 20 mEq of K at 75 mL/Hr. The provider has prescribed 1 g of ceftriaxone IV. When preparing to administer this medication by intermittent IV bolus, which of the following actions should the nurse take first?
Verify the medication's compatibility with the primary IV solution
a nurse is inserting a peripheral IV catheter and observes a blood return in the flashback chamber after puncturing the skin and selected vein. Which of the following actions should the nurse perform next?
advance the catheter into the vein with the finger hub.
A nurse has just inserted a peripheral IV catheter. Which of the following actions should the nurse take to secure the catheter?
apply an IV securement device
a nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect?
beefy red tongue
a nurse is preparing to inspect the outer ears of a client who has been in an MVA. The nurse should identify that which of the following findings indicates the client might have a skull fracture?
bloody drainage
A nurse is performing a focused assessment on a client who reports having difficulty swallowing and a continuous headache. The nurse should identify that these findings can indicate which of the following condition?
central nervous system disorder
a nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing?
cheyne-strokes breathing
a nurse is assessing an older adult client's mouth. The nurse should identify that which of the following is expected variation for this client?
darkening of the mucosa
a nurse is assessing the eye of a client who experienced a subconjuctictival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect?
defined reddened area of the sclera
When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand?
the inner edge of the cuff will lie against the skin an thus will not be sterile.
a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene?
the nurse is auscultating through the client's gown
a nurse is performing a head-to-toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions?
thyroid disorder
A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis?
to control the introduction of micro-organisms at the catheter site.
a nurse should identify that which of the following is the goal of surgical asepsis?
to create and maintain a micro-organism-free environment
A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows?
to encourage water and soap to flow awat from the clean hands
a nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye?
transparent layer that covers the iris and pupil.
A nurse is preparing to give an intramuscular injection into the left ventrogluteal mucle. Which of the following actions should the nurse take to locate the site of injections?
use the heel of the hand and the index finger to locate the vastus lateralis muscle
a nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations performed on a regular basis? (select all that apply)
vision screening every other year dental exam
a nurse is auscultating the lateral lobes of a client who has bronchitis. The nurse should document the sound as which of the following?
wheeze
a nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect?
white patches on the tongue
