practice exam
The nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. which parameter should nurse assess first?
Airway patency
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and fresh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer.
basal cell carcinoma
a nurse is caring for a client who has fallen while getting out of bed States quotation I'm okay I guess I should have called for help the bathroom quotation after assisting the client the nurse identifies a provider. Which of the following documentation should the nurse include in the client's medical record?
"the ptovider was notified"
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
A dry, red rash across the bridge of the nose and cheeks
a nurse asks a client how he is feeling. the client states "i'm feeling a bit nervous today". which response should the nurse make?
explain the word nervous
Nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
frequent mood changed
A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?
gallstones
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
"Do you have difficulty staying awake when you are driving?
A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?
"Documentation is a communication tool for the interprofessional health care team."
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion
-More difficulty seeing due to a greater sensitivity to glare-Decreased cough reflex-Decreased bladder capacity-Dehydration of intervertebral discs
A nurse is caring for a client who's has emphysema. Which of the following findings should the nurse expect to assess in the client? (Select all that apply.)a. Dyspneab. Bradycardiac. Barrel chestd. Clubbing of the fingers
A C D
A nurse is assessing the reflexes of a client who has an unrepaired femur fx and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?
Dorsiflexion of the great toe
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
Dysmenorrhea that is unresponsive to NSAIDS.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
Dysphagia
A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
Ecchymosis
A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors?
asking if they took medicatiobs in the morning
Avoid assessing _____ pulse bilaterally
carotid
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
edema
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
increased anteroposterior diameter of chest
a nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which assessment would indicate to the nurse that the client could be developing a serious complication?
increased resp rate from 18 to 44/min
which of the following assesments will give the nurse information about CN III
instruct client to look up and down without moving head
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the followingmanifestations should the nurse expect?
intercostal retractions
cushing syndrome manifestations
moon face alopecia purple strations biffalo hump
a nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect?
painful lesions following a nerve pathway
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
perform neurovascular assessment
A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? Prior to percussing the abdomen
prior to inspecting the abdomen
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching?
race
A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?
repear auscultation after asking client to breath deeply and cough
A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?
vertigo
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. the client tells the nurse that she is scared and wishes she never smoked.
its okay to feel scared. lets talk about it
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? Select all that ApplyA. Contractors of the extremitiesB. PolyuriaC. DiarrheaD. Crackles in the lungsE. Pressure ulcers
A D E
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
A. Oral mucosa
A nurse is caring for a client who has dementia. When performing a mental status examination the nurse should include which of the following data?
Ability to perform calculationsRecall abilityLong-term memorylevel of orientation
A nurse is caring for a client who has an unrepaired femur fracture of the mid shaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?
Instruct the client to wiggle his toes
nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?
Has alcohol use affected your performance at work?"
A nurse in a provider's office is assessing an older client whose son reports that the client has been sick with respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
confusion
A nurse is assessing for cyanosis in a client who has dark skin. which of the following sites should the nurse examine to identify
conjunctivae
cataracts
having decreased abilty to perceive colors
heart sounds between s1 and s2
systolic murmur
A nurse is assessing a client for pitting edema and notes indentation of 6mm (0.25in) at point of pressure. which of the following is the appropriate doc of edema?
3 +
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
Cheyne-stokes respirations
a nurse is assessing an older adult client who has osteoporosis. Expect the following spinal deformities
Kyphosis
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. This is most likely an indication of which of the following conditions?
atelectasis
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause?
dryness with intercourse
a nurse is caring for an adult who has atopic dermatitis. which of the following findings should the nurse expect
chronic rash with thick skin
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
cigarette smoking
Nurse assessing client who has REA score of 6 on Glasgow Coma scale. The nurse should expect what outcome based on this score?
client needs total nursing care
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
weakness
A nurse is auscultating breath of a pt who had asthma. When the pt exhales, the nurse hears continuous high pitched squeaking sounds. What is this finding,
wheezes
A nurse in an acute mental health facility is caring for a client who has major depressive disorder. Since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make?
"I see that you have on clean clothes and have combed your hair."
A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following tests should the nurse expect the provider to use?
A Papanicolaou test
A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?
A self-report pain rating scale
A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?
A small, translucent papule with rolled borders
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
Before the examination your provider will give you a sedative that will make you sleepy
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?
History of NSAID use
A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?
Increased HR
A nurse is performing a pre college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering?
Meningococcal polysaccharide vaccine
A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take?
Obtain information about the client's recent sexual experiences
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Poor skin turgor, hypotension, flat neck veins
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?
The client's sociocultural background influences nonverbal
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?
The left second intercostal space
A nurse is assessing a client who was involved in a motor-vehicle crash. Which of the following techniques should the nurse use to test corneal reflexes?
The nurse should lightly touch a cornea with a wisp of cotton. Absent corneal reflexes, or the loss of the ability to blink, can be caused by a head injury or stroke.
a nurse is auscultating the lungs of a cliebt who has pluerisy.
loud, scratchy sounds
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
self report
A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?
serpignous
a nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect
severe headache
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? Smokes 1 pack of cigarettes per day.
smokes 1 pack of cigarettes per day
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?
tachycardia