RNSG 1111 Unit 4 Study Set #4 Practice Questions

A nurse is assessing a client for conductive hearing loss. When using the Rinne Test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A: Air conduction is less than bone conduction in the left ear B: Air conduction is greater than bone conduction in the left ear. C: Sound is materializing to the right ear. D: Sound is materializing to the left ear

A: Air conduction is less than bone conduction in the left ear -This finding indicates conductive hearing loss of the left ear

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A: Below the medial malleolus B: In the popliteal fossa C: In the antecubital space D: On the dorsal of the foot

A: Below the medial malleolus -The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle.

A nurse is performing neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A: Cranial Nerve XII B: Cranial Nerve X C: Cranial Nerve VIII D: Cranial Nerve V

A: Cranial Nerve XII The nurse is checking the function of cranial nerve XII (hypoglossal), which innervates the tongue by observing a range of tongue movements.

A nurse is caring for a client who has dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficient? A: Obtain the apical and radial pulses simultaneously B: Check the blood pressure in the left and right arms C: Compare the pulse strength in the upper extremities D: Palpate the pulses in the lower extremities

A: Obtain the apical and radial pulses simultaneously -To assess for a pulse deficit, the nurse and a second person assess the client's radial and apical pulses simultaneously and they compare both rates.

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A: Osteoporosis B: Scoliosis C: Kyphosis D: Lordosis

A: Osteoporosis -A loss in height can indicate an early detection of osteoporosis

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A: Vesicular B: Bronchial C: Rhonchi D: Bronchovesicular

A: Vesicular

A nurse is teaching a client to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A: With your palm facing down, move your wrist sideways toward your thumb. B: Move your palm toward the inner part of your forearm C: With your palm facing down, move your wrist sideways toward your little finger. D: Bring the back of your hand as far back toward the wrist as you can

A: With your palm facing down, move your wrist side-ways toward your thumb.

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The manifestation is consistent with which of the following eye disorders? A: Retinopathy B: Glaucoma C: Cataracts D: Macular degeneration

B: Glaucoma

A nurse is measuring a client's vital signs. The client's resting radial pulse is 55/min. Which of the following actions should the nurse take next? A: Document the findings B: Measure the client's apical pulse rate C: Talk with the client about factors that can affect the pulse rate D: Notify the provider about the client's radial pulse rate

B: Measure the client's apical pulse rate

A nurse is performing a physical assessment of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A: Heart B: Lungs C: Thyroid Gland D: Skin

B:Lungs -The lungs are hollow organs that can produce sound like a resonance or dullness.

In this type of faith, male family members prepare the body following death for individuals practicing this type of faith:

Buddhist faith

During a physical examination of client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data: A: Confrontation test B: Symmetry of palpebral fissures C: Corneal light reflex D: Accommodation test

C: Corneal light reflex -With strabismus, the eyes will not align when the client focuses.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse grab for the test? A: Sugar B: Coffee C: Cotton wisps D: Snellen chart

C: Cotton Wisps -The nurse should realize cranial nerve V has both sensory and motor function. To assess it's sensory function, the nurse should use a safety pin to assess for recognition of pain and a cotton wisp to evaluate the recognition of touch sensations.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the newly statements by the newly licensed nurse indicates an understanding of the teaching? A: People who practice Islamic faith pray over the deceased for period of 5 days before burial. B: People who practice the Hindu faith bury the deceased with their head facing north C: People who practice Judaism stay with the body of the deceased until burial. D: People who are practicing Buddhist faith have the family family members prepare the body following death.

C: People who practice Judaism stay with the body of the deceased until burial.

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A: Peripheral pulses equal bilaterally at a rate of 60/min B: Radial, brachial, and pedal pulses bilaterally weak C: Peripheral pulses bilaterally symmetric ,equal, and strong in all 4 extremities. D: Brachial, radial, popliteal, and dorsalis pedis pulses, 58, and bilaterally palpable

C: Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities Documentation of peripheral pulses should include the strength of pulsations, equality, and symmetry in all 4 extremities.

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A: "Tilt your head slightly forward" B: "Keep your head straight and look ahead of you" C: "Tilt your head back and swallow D: "Turn your head back to the side against my hand"

C: Tilt you head back and swallow

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected range reference? A: Pulse rate 90/min B: Rectal temperature 38'C (100.4'F) C: Pulse oximetry 95% D: BP 145/90 mmHG

D: BP 145/90 mmHG - This blood pressure is greater than the expected blood pressure

A nurse documents the presence of clubbing on the finger nails for a client who has emphysema. Which of the following is the underlying cause of this finding? A: Trauma B: Severe infection C: Iron-deficiency anemia D: Chronic hypoxemia

D: Chronic hypoxemia -Clubbing of the nails is a sign of chronic hypoxemia (low oxygen supply) such as with COPD

A nurse is changing the dressing for a client recovering from appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A: Tenderness when touched B: Pink, shiny tissue, with a granular appearance C: Serosanguineous drainage D: Halo of erythema on the surrounding skin

D: Halo of erythema on the surrounding skin -This could indicate an underlying infection

A nurse is determining physical examination for the client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A: Percussion B: Auscultation C: Inspection D: Palpation

D: Palpation -With Palpation, the nurse uses uses touch to help detect unusual or expected sensations including texture, temperature, masses, or moisture

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A: Perform a Romberg Test B: Check nails for Beau's lines C: Palpate for respiratory excursion D: Perform a blanch test

D: Perform a blanch test -The blanch is used to check for capillary refill, which is an indicator of peripheral circulation and tissue perfusion.

A nurse is obtaining blood pressure in the client's lower extremities. Which of the following action should the nurse take? A: Auscultate the blood pressure at the dorsals pedis B: Measure the blood pressure with the client sitting on the side of the bed. C: Place the cuff 7.6 cm above the popliteal artery D: Place the bladder of the cuff over the posterior aspect of the thigh

D: Place the bladder of the cuff over the posterior aspect of the thigh -This is the correct position for the bladder of the cuff when the nurse is assessing lower extremity blood pressure.

A nurse at a screening facility is assessing a client who reports a history of a heart murmur related to the aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A: Fifth intercostal space just medial to the midclavicular line B: Second intercostal space to the left of the sternum C: Fifth intercostal space to the left of the sternum D: Second intercostal space to the right of the sternum

D: Second intercostal space to the right of the sternum

For those who practice this type of faith, they place the body with the head facing north following death. However, after cremation rather than burial is practiced by those of this Fatih.

Hindu faith

For those who practice this faith, the body of the deceased is washed and wrapped during during a ritual then buried as soon as possible following death.

Islamic faith