HESI

A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take? A. Stop the infusion B. Change the dressing bandage C. Remove epidural catheter D. Contact HCP immediately

A

A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? A. Vitamin B12 injections B. Vitamin B6 injections C. An antibiotic D. An antacid

A

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? A. Waves of loud gurgles auscultated in all 4 quadrants B. Low-pitched swishing auscultated in 1 or 2 quadrants C. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants D. Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants

A

The RN is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? A. Check pH of aspirated stomach contents obtained from the NGT B. Auscultate over the epigastrium while injecting air into the NGT C. Disconnect and place the end of NGT in water to see if bubbles appear D. Listen for hyperactive bowel sounds in all 4 quadrants of abdomen

A

The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? A. "My pulse rate should be less than what my pacemaker is set at." B. "I'll need to call my health care provider if I feel tired or dizzy." C. "I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." D. "It's safe to use my microwave as long it is properly grounded and well shielded."

A

The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? A. Applying warm compresses to the affected area B. Placing iced compresses to the affected area every 4 hours C. Alternating the application of hot and iced compresses every 2 hours D. Placing antibiotic ointment on the affected site followed by continuous heat lamp application

A

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? A. Elevated serum lipase level B. Elevated serum bilirubin level C. Decreased serum trypsin level D. Decreased serum amylase level

A

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? A.Hypotension B. Flat neck veins C. Complaints of nausea D. Complaints of headache

A

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain

A

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? A. The major bronchi B. The trachea and larynx C. The peripheral lung fields D. The lower posterior thorax

A

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? A. Mitral area B. Right atrium C. Right ventricle D. Pulmonic valve

A

The nurse monitors the client for which condition as a complication of polycythemia vera? A. Thrombosis B. Hypotension C. Cardiomyopathy D. Pulmonary edema

A

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? A. Rhythmic respirations with periods of apnea B. Regular rapid and deep, sustained respirations C. Totally irregular respiration in rhythm and depth D. Irregular respirations with pauses at the end of inspiration and expiration

A

The nurse has given a client who is at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states that the medication is taken at what time before the triggering event? A. At least 2 days before B. At least 1 hour before C. At least the day before D. At least a half-day before

B

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action? A.Focus on a close object. B. Focus on a distant object. C. Close 1 eye and read letters on a chart. D. Raise 1 finger when the sound is heard.

B

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? A. Ask the client to puff out the cheeks. B. Separate the client's jaw by pushing down on the chin. C. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. D. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

B

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note? A. Weight loss B. Peripheral edema C. Capillary refill of 5 seconds D. Bleeding from previous puncture sites

B

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? A. Pallor B. Low arterial PaO2 C. Elevated arterial PaO2 D. Decreased respiratory rate

B

The nurse is caring for a young adult who is having an oral glucose tolerance test (OGTT). Which lab result should the nurse assess as a normal value for the two postprandial result? A. 200 mg/dl B. 140 mg/dl C. 160 mg/dl D. 180 mg/dl

B

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective? A. "Variant angina is induced by exercise." B. "Variant angina occurs at the same time each day." C. "Variant angina occurs at lower levels of activity." D. "Variant angina is less predictable and a precursor of myocardial infarction."

B

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II? A. Flashlight B. Snellen chart C. Reflex hammer D. Ophthalmoscope

B

The nurse palpates a small, round and tense area immediately above the client's symphysis pubis. This assessment finding is consistent with: A. Constipation B. Urinary retention C. Urinary tract infection D. Abdominal aortic aneurysm

B

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? A. "It will open up the major airways." B. "It will keep the small airways open." C. "It will increase lubrication for the lungs." D. "The lungs can better rid themselves of secretions."

B

The RN is administering haloperidol 0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during the initial dose? A. Bradykinesia B. Dystonia C. Somatization D. Akathisia

B (Dystonia can be a sudden adverse reaction to psychotropic medication which should be discontinued to resolve dystonia)

During a physical assessment, the nurse gently pinches the skin over the client's forearm and observes for tenting. For which health problem is the nurse assessing in this client? A. Malnutrition B. Dehydration C. Decubitus ulcer D. Deep vein thrombosis

B (Rationale: assessing skin turgor is a technique used to evaluate a patient's hydration status)

A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? A. Palpating over the lung apices in the supraclavicular area B. Asking the client to repeat the word ninety-nine during palpation C. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other D. Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine

C

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? A. Waves of loud gurgles auscultated in all 4 quadrants B. Low-pitched swishing auscultated in 1 or 2 quadrants C. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants D. Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants

C

An older client is admitted to the hospital with severe diarrhea. The RN is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? A. Cheyne-stokes respiration B. Elevated blood pressure C. Orthostatic hypotension D. Lower extremity edema

C

Physical symptoms of meningitis, severe neck stiffness, causes patients hips and knees to flex when the neck is flexed. A. Dystonia B. Kernig's sign C. Brudzinski's sign D. Sarcoidosis

C

The RN is assessing a male patient who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the patient has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the patient about his medical history? A. Irritable Bowel Syndrome B. Crohn's disease C. Ulcerative colitis D. Diverticulitis

C

The RN is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client is uncomfortable with the nurse. B. The client is purposefully disrespecting the nurse. C. The client is treating the nurse with respect. D. The client cannot understand the nurse

C

The RN uses the mini-mental state exam (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? A. Recall of information B. Orientation to surroundings C. Attention to details D. Ability to follow complex commands

C

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? A. Ataxia B. Nystagmus C. Pronator drift D. Hyperreflexia

C

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? A. Heart rate B. Skin color C. Status of airway D. Peripheral pulse strength

C

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? A. A tubing obstruction or kink B. The accumulation of secretions C. Disconnection of the ventilator tubing D. Condensation of water in the ventilator tubing

C

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? A. Flat neck veins B. A pulse rate of 60 beats/minute C. Muffled or distant heart sounds D. Wheezing on auscultation of the lungs

C

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? A. Evaluating for asterixis B. Inspecting for petechiae C. Palpating for peripheral edema D. Evaluating for decreased level of consciousness

C

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client? A. Complaints of ringing in the ear B. An excessive amount of cerumen in the ear canal C. Intolerance for sound levels that do not bother other people D. Complaints of dizziness and sensations of being "off balance"

C

Low urine output:

oliguria

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider (HCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? A. Atelectasis and viral infection B. Bronchoconstriction and stridor C. Collapse of alveoli and decreased compliance D. Decreased ciliary action and retained secretions

C

The nurse would perform which action to assess for a pulse deficit? A. Count the carotid pulsations for one full minute. B. Measure the blood pressure in both the arm and leg. C. Auscultate the apical heart beat while palpating the radial artery. D. Place the diaphragm of the stethoscope directly over the skin at the mitral area.

C

The registered nurse (RN) is listening to a lecture on pulmonary edema. Which statement by the RN indicates that the teaching has been effective? A. "The client may have mild anxiety." B. "The client will not experience anxiety." C. "The client will experience extreme anxiety." D. "The client will only experience anxiety in a stressful environment."

C

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? A. Lub-dub sounds B. Scratchy, leathery heart noise C. A blowing or swooshing noise D. Abrupt, high-pitched snapping noise

C

A client with diabetes mellitus is diagnosed with chronic arterial insufficiency. What will the nurse most likely assess in this client? A. Elevated blood glucose levels B. Smooth skin with even hair growth C. Diminished dorsalis pedis pulses D. Distant bowel sounds

C (Rationale: diminished pulses of the lower extremities are an assessment finding consistent with chronic arterial insufficiency.)

A client makes an appointment with an ear specialist because of the frequent recurrence of middle ear infections. In performing an intake assessment of the client, the nurse should ask about which risk factor related to infection of the ears? A. Occupational noise B. Exposure to loud noise C. Congenital abnormalities D. Use of drilling and other power tools

C (otis media (middle ear infection) is associated with colds, allergies, sore throats; risk factors include congential abnormalities, immune deficiencies)

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique? A. Tapping the Achilles tendon using the reflex hammer B. Gently pricking the client's skin on the dorsum of the foot in 2 places C. Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument D. Holding the sides of the client's great toe and, while moving it, asking what position it is in

D

Which is a symptom of diabetes insipidus? A. High fever B. Low blood pressure C. Weight gain D. polydipsia

D

What finding will cause the nurse to suspect a newborn is dehydrated? A. Bulging fontanel B. Acrocyanosis C. Warm, clammy skin D. Rapid pulse

D (Rationale: a rapid pulse, dry mucous membranes and a sunken fontanel, decreased capillary refill and increased breathing frequency are all signs of dehydration)

The RN is teaching a client who is newly diagnosed with emphysema how to perform pursued lip breathing. What is the primary reason for teaching the client this method of breathing? A. Decreases respiratory rate B. Increases O2 saturation throughout the body C. Conserves energy while ambulating D. Promotes CO2 elimination

D (Reasoning: pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli which makes it easier to expel air from the lungs)

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? A. Dry sterile dressing B. Wet to dry dressing C. Gelfoam sponge dressing D. Semipermeable film dressing

D (Semipermeable dressings are applied to superficial wounds, ulcers, occasionally on some deep, draining or necrotic ulcers.)

The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective? A. "Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." B. "Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." C. "Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." D. "Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle."

A

A RN is assessing common complications related to systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? A. Fever related to infection B. Weight loss C. Depressed mood D. Break in tissue integrity

A (Secondary infections are a major concern with SLE patients because of the medications that supress their immune systems)

A

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? A. Just under the left clavicle B. Midsternum, 1 inch to the left C. Over the fifth intercostal space D. Midsternum, 1 inch to the right

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. A. Dyspnea at rest B. Clubbed fingers C. Muscle retractions D. Decreased respiratory rate E. Increased body temperature F. Prolonged expiratory breathing phase

A, B, C, F

The RN is caring for a patient with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? Select all that apply. A. Hematemesis B. Gastric pain on an empty stomach C. Colic-like pain with fatty food ingestion D. Intolerance of spicy foods E. Diarrhea and stearrhea

A, B, D

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. A. Cough B. Dyspnea C. Weight gain D. High-grade fever E. Chills and night sweats

A, B, E

The nurse is assessing a client's left lumbar region of the abdomen. Which organ will the nurse assess through this region? Select all that apply. A. Descending colon B. Spleen C. Stomach D. Lower half of left kidney E. Sigmoid colon

A, C

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply) A. Diminished hair on the legs B. Bruising on extremities C. Skin cool to touch D. Darkened skin on extremities E. Capillary refill less than 3 seconds

A, C (Reasoning: diminished hair on legs and skin that is cool are symptoms of decreased arterial blood flow)

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. A. Encourage coughing with deep breathing. B. Place in high Fowler's position for eating. C. Encourage increased oral intake of water daily. D. Place thigh-length elastic stockings on the client. E. Place sequential compression boots on the client. F. Encourage the intake of dark green, leafy vegetables.

A, C, D

An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. A. Heels B. Ankles C. Elbows D. Sacrum E. Back of the head F. Greater trochanter

A, C, D, E

A client with progressive hearing loss appears distressed when the RN asks open-ended questions about the client's health history. Which form of communication should the RN use? (select all that apply) A. Face the client so the client can see the RN's mouth B. Increase one's speech volume when interacting with client C. Repeat information to client if misunderstood D. Check if the client's heading aides are working properly. E. Reduce environmental noise surrounding the client

A, D, E

The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. A. Lips B. Tongue C. Earlobes D. Conjunctiva E. Mucous membranes

A, D, E

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? A. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L B. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L C. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L D. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

B

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A. A defect in cranial nerve VIII B. A physical obstruction to the transmission of sound waves C. A defect in the cochlea D. A defect in the sensory fibers that lead to the cerebral cortex

B

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? A. Anterior chest pain B. Pericardial friction rub C. Weakness and irritability D. Chest pain that worsens on inspiration

B

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? A. Rice B. Whole milk C. Broiled fish D. Baked chicken

B

A client is newly diagnosed with diverticulosis. The RN is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. B. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. C. Diverticulosis is the result of high fiber diet and sedentary life style D. Over use of laxatives for bowel regularity results in loss of peristaltic tone

B

A client with otitis media reports feeling something "pop" inside the ear. What does this information suggest to the nurse? A. Client's tympanic membrane perforated B. Client's eustachian tubes collapsed C. Client's ear pain will resolve shortly D. Client is likely to develop dizziness and vertigo

B

An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? A. Purpura B. Venous star C. Spider angioma D. Cherry angioma

B

Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte? A. Calcium B. Potassium C. Magnesium D. Phosphorus

B

The RN assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? A. pH of 7.45, pCO2 37mmHg, HCO3 24 mEq/L B. pH 7.32, pCO2 46 mmHg, HCO3 24 mEq/L C. pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L D. pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L

B

After a liver biopsy is performed at the bedside, the nurse is assigned the care of the client. Which nursing intervention is most important for the the nurse to implement? A. Position client on left side with pillow placed under the costal margin B. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure C. Ambulate client 3 times in first hour with pillow under abdomen D. Assist client with voiding immediately after the procedure

B (Reasoning: this is assessing for bleeding after biopsy, which liver is highly vascular. Client should be positioned on the right side, not the left. Client should be maintained on bedrest for several hours to decrease risk of bleeding from biopsy site)

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. A. Allergy to pollen B. History of headaches C. Previous back injury D. History of hypertension E. History of diabetes mellitus

B, C, D, E

Which are possible causes of upper airway obstruction? Select all that apply. A. Thin secretions B. Laryngeal edema C. Head and neck cancer D. Foreign body aspiration E. Lymph node enlargement

B, C, D, E

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. A. Purified air B. Cigarette smoking C. Genetic risk factor D. Environmental factors E. Eating plenty of fruits and vegetables F. Alpha-1 antitrypsin (AAT) deficiency

B, C, D, F

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. A. Sclerae B. Tongue C. Nail beds D. Elbows and heels E. Mucous membranes

B, C, E

A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? A. Eat breakfast just before the procedure. B. Wear firm, rigid shoes, such as work boots. C. Wear loose clothing with a shirt that buttons in front. D. Avoid cigarettes for 30 minutes before the procedure.

C

A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms. The client suddenly complains of chest pain. Which question should best help the nurse discriminate pain caused by a non-cardiac problem? A. "Can you describe the pain to me?" B. "Have you ever had this pain before?" C. "Does the pain get worse when you breathe in?" D. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

C

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? A. "I will ask the client to raise the legs up to the waist and then to lower the legs slowly." B. "I will ask the client to raise the legs and to try to lower them against pressure from my hand." C. "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." D. "I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."

C

The RN is making early morning rounds when a client begins showing symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? (Select all that apply) A. Tachycardia B. Increased BP C. Rapid resolution of wheezing D. Improved pulse oximetry values E. Reduce fever airway inflammation

C, D

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? A. Assess for drainage from the wound. B. Assess for redness around the wound edges. C. Palpate for swelling around the wound edges. D. Palpate for increased skin temperature around the wound edges.

D

A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? A. Anemia B. Hypothyroidism C. Diabetes mellitus D. Chronic kidney disease

D

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test? A. The client is asked to discriminate numbers from a chart composed of colored dots. B. The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field. C. The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field. D. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

D

A male client is admitted after falling from his bed. The HCP tells the family that he has an incomplete fracture of the humerus. The family asks the RN what this means. Which type of fracture should the RN explain from these findings? A. Straight fracture line that is also a simple, closed fracture B. Nondisplaced fracture line that wraps around the bone C. A complete fracture that also punctures the skin D. A fracture that bends or splinters part of the bone

D

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? A. Increased heart rate and increased blood pressure B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure

D

An older male client is experiencing urinary dribbling, frequency and difficulty starting the stream. For which health problem should the nurse assess the client? A. Urinary incontinence B. Urinary tract infection C. Testicle cancer D. Enlarged prostate gland

D

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring? A. A P wave preceding every QRS complex B. QRS complexes that are short and narrow C. Inverted P waves before the QRS complexes D. Premature beats followed by a compensatory pause

D

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? A. Over the second intercostal space at the left sternal border B. Over the fourth intercostal space at the right sternal border C. Over the second intercostal space at the right sternal border D. Over the fifth intercostal space in the left midclavicular line

D

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retractions D. Increased respiratory rate

D

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? A. Stay very still. B. Exhale very quickly. C. Inhale and exhale quickly. D. Perform the Valsalva maneuver.

D

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. A. Presence of striae B. Palpable radial pulses C. Absence of any ecchymosis on the extremities D. Thinner and decrease in number of reddish papules E. Scarce amount of silvery-white scaly patches on the arms

D, E

Inability of the child to extend the legs fully when lying supine.

Kernig's sign

Which sound occurs with closure of the AV valves and thus signals the beginning of systole?

S1

Which sound occurs with closure of the semilunar valves and signals the end of systole?

S2 (S2 is loudest at the base)

Which sound occurs when the ventricles are resistant to filing during the early rapid filling phase?

S3

Which sound occurs at the end of diastole, at presystole, when the ventricle is resistant to filling?

S4

Asking a client to repeatedly say "99" is called _______________.

bronchophony

Normal color of tympanic membrane

gray (pink, white or red membrane may indicate infection)