Nursing Test 2

Which are considered vital signs? Select all that apply. temperature allergies pulse weight respiratory rate blood pressure

temperature pulse respiratory rate blood pressure

A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate? - "I want to reposition the client to reduce the risk of skin breakdown." - "I am placing the new linens under the rolled, soiled lines to avoid contamination." - "The position of the client helps me to assess skin integrity before performing a back massage." - "This is not a trochanter roll. I am tucking the draw sheet tightly so it does not move when the client is in bed."

"I am placing the new linens under the rolled, soiled lines to avoid contamination."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use a washcloth to clean the auricles and cerumen when needed." "I use cotton-tipped applicators daily to remove cerumen." "I never use bobby pins or other sharp objects when cleaning cerumen." "I clean my ear mold on my hearing aid daily before use."

"I use cotton-tipped applicators daily to remove cerumen."

A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply. - "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." - "It is important to include hair care and shampooing along with brushing in your hygiene routine." - "Hygiene measures have no affect on skin." - "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." - "Bathing regularly and applying lotion and cream as needed are important."

"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin."

A licensed practical nurse (LPN) is making an unoccupied bed in preparation for a new admission. What response should the registered nurse (RN) provide to encourage appropriate, effective bedmaking technique and effective use of resources? - "Since the bed linen is clean, gloves are not necessay unless you are coming into contact with contamined linen." - "Since your bedmaking technique is appropriate, I'll have you check the new nursing assistants during their orientations." - "You are demonstrating effective, appropriate bedmaking techinque that also shows an understanding of good use of resources." - "You should spread the sheet out on the entire bed initally to minimize the spread of microorganisms."

"Since the bed linen is clean, gloves are not necessay unless you are coming into contact with contamined linen."

A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate? "Please tell me what products you use for washing your hair." "Tell me about what you do to take care of your hair." "Tell me why you do not want me to wash your hair." "How often do you wash your hair?"

"Tell me about what you do to take care of your hair."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? - "All of these spots are called seborrheic keratoses and they should be taken off." - "I know these spots are called senile lentigines and they are likely cancer." - "These brown spots are senile lentigines and are common when you get older." - "Older people often have splotchy skin due to seborrheic keratoses."

"These brown spots are senile lentigines and are common when you get older."

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? "Are you having any pain?" "Do you have any allergies?" "What brings you here today?" "What medications do you normally use?"

"What brings you here today?"

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury? - An intact faded purple area on the shoulder blades, with a yellowish tint. - An intact red area on the buttocks. - A circular red, scaly area that itches on the top of the forearm arm. - An area of swollen, pale red bumps on the front of the neck.

An intact red area on the buttocks.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? Place the client in a semi-Fowler's position. Warm the equipment. Ask the client to empty her bladder. Measure height and weight.

Ask the client to empty her bladder.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? Page the client's primary care provider. Auscultate the client's apical heart rate. Reassess the client's radial pulse in 15 minutes. Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate

A nurse is providing nail care for feet to clients admitted to a health care facility. What should the nurse look for while performing nail care for a client with a long history of diabetes? A bony bump on the joint at the base of the big toe Breaks in skin integrity and fungal nail infection Cold feet Redness and swelling in the joint of the big toe with reports of pain

Breaks in skin integrity and fungal nail infection

The nurse is teaching a client about hearing aid care. Which teaching is appropriate? Select all that apply. - Use a small knife to remove cerumen that becomes embedded in the earpiece. - Carefully wipe the outer surface of the hearing aid to maintain cleanliness. - Store the hearing aid in a very warm environment so that it will not crack. - Do not get hair spray or other chemicals on the hearing aid. - Keep extra batteries on hand.

Carefully wipe the outer surface of the hearing aid to maintain cleanliness. Do not get hair spray or other chemicals on the hearing aid. Keep extra batteries on hand.

During morning care, client who is postoperative day 1 blinks excessively and has dried secretions in the corners of the eyes. Which step(s) does the nurse include in eye care for the client? Select all that apply. - Cleans from the inside of the eye toward the outside - Cleans the eyes with a washcloth or cotton ball soaked with saline or sterile water - Cleans each eye with a different wash cloth soaked in boric acid - If a visual aid is used, it will be located and its use encouraged - If infection is not suspected, cleans each eye with a different part of the washcloth

Cleans from the inside of the eye toward the outside Cleans the eyes with a washcloth or cotton ball soaked with saline or sterile water If infection is not suspected, cleans each eye with a different part of the washcloth

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? Each lub-dub is two beats. The lub-dub sounds occur within 2 seconds of each other. Heart sounds are caused by the opening of heart valves. Each lub-dub is one beat.

Each lub-dub is one beat.

The nurse is performing bilateral comparison of pulse sites for strength and quality instead of counting the beats per minute. Which pulse locations will the nurse palpate to gather this assessment data? Select all that apply. Femoral Apical Dorsalis pedis Popliteal Posterior tibial

Femoral Dorsalis pedis Popliteal Posterior tibial

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature? Increase the client's metabolic rate. Set up a fan to blow warm air on the client. Give the client a bath in tepid water. Apply a blanket on the client.

Give the client a bath in tepid water.

A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease? Inspect and palpate the supraclavicular area. Inspect and palpate the left and then the right carotid arteries. Palpate the thyroid gland. Inspect the client's ability to move his neck.

Inspect and palpate the supraclavicular area.

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first? Inspect the area of itchy skin. Check her chart for allergy information. Review her medical history. Review her medication record.

Inspect the area of itchy skin.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. Symmetrical shape Single color Irregular edges Change in the mole Larger than 1/4 inch in diameter

Irregular edges Change in the mole Larger than 1/4 inch in diameter

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? Need for readjustment is eliminated. No stethoscope is required. Inexpensive depending on quality. Ability to read gauge from any direction.

No stethoscope is required.

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which solution should the nurse use for the storage of the client's lenses after removal? Hypertonic solution Sterile water Hypotonic solution Normal saline

Normal saline

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? Palpate one artery at a time. Palpate both arteries at the same time. Measure the rate for 30 seconds and multiply by 2. Measure the rate for 1 full minute.

Palpate one artery at a time.

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? Percussion Inspection Palpation Auscultation

Palpation

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment? Doppler ultrasound Bladder scanner Syringe Penlight or flashlight

Penlight or flashlight

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest? Providing multiple stimuli to make the client tired Engaging in a therapeutic conversation Providing a back rub before bed Giving the client something to drink

Providing a back rub before bed

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? Mouth Axilla Ear Rectum

Rectum

Which nursing action is appropriate when providing foot care for a client? - For diabetic clients, trim the nails with nail clippers. - Soak the feet in a solution of mild soap and tepid water. - Cut off any corns or calluses. - Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

Which statement accurately represents a characteristic of the third or fourth heart sound? - S3 is best heard with the stethoscope bell at the mitral area, with the client lying on the right side. - S3 is considered normal in children and young adults and abnormal in middle-aged and older adults. - S4 is considered normal in children and adults but abnormal in older adults. - S4 is the fourth heart sound, represented by "lub-dub-dee."

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this? The client is covered with a couple of thick blankets. The thermometer is broken. A rectal thermometer must be used. The client is showing initial signs of infection.

The client is covered with a couple of thick blankets.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take? - The nurse should have a male nurse bathe the client. - The nurse should call a family member and have him or her bathe the man. - The nurse should bathe the man herself, as he has dementia. - The client should be allowed to complete as much of the bath as he can.

The client should be allowed to complete as much of the bath as he can.

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? The client's most recent temperature The client's nutritional status The client's wellness goals Preferred site for temperature assessment

The client's most recent temperature

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results? - The client's reaction time will likely be slower than that of a younger adult. - The client will likely have difficulty expressing or understanding abstract concepts. - The client will experience lapses in short- and long-term memory. - The client's arm and leg strength will be more asymmetric than that of a younger client.

The client's reaction time will likely be slower than that of a younger adult.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The radial pulse is difficult to obtain. The blood pressure is elevated. The carotid pulse is bounding. A baseline pulse rate is needed.

The radial pulse is difficult to obtain.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: clear. blurred. 20/20. clouded.

blurred.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client? Wait for 15 to 20 minutes before measuring the oral temperature Ask the client to drink a glass of cold water before measuring the oral temperature Obtain the client's temperature rectally after lubricating the rectum Use the axillary site for an alternate measurement site

Wait for 15 to 20 minutes before measuring the oral temperature

Which client would the nurse consider at risk for low blood pressure? a client with high blood viscosity a client with decreased elasticity of walls of arterioles a client with a strong pumping action of blood into the arteries a client with low blood volume

a client with low blood volume

When percussing the liver, the sound should be: resonant. hyperresonant. dull. flat.

dull

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: - fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. - fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. - fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow. - fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of: subjective data. baseline data. objective data. comprehensive data.

objective data.

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? oriented to hospital, person, and date oriented to person, place, and time oriented to person, place, and situation oriented to person, situation, and time

oriented to person, place, and time

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? pulmonary embolism coronary artery disease chronic obstructive pulmonary disease (COPD) peripheral vascular disease

peripheral vascular disease

The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention? rectal tympanic oral axillae

rectal

A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water. How will this affect my children?" It is important for the nurse to educate the mothers that: there is a need to determine if the bottled water has fluoride. the preschool child should only drink milk. the parent should alternate bottle and tap water. the preschool child should not drink bottled water.

there is a need to determine if the bottled water has fluoride.