T3 Content Mastery
A nurse is performing a physical assessment of a patient. When conducting the initial observations, which of the following would the nurse be LEAST likely to include? Select all that apply. 1) Posture 2) Movement symmetry 3) Auscultation of blood pressure 4) Percussion of the lungs 5) Speech pattern 6) Palpation of the abdomen
Correct Response: Percussion of the lungs Palpation of the abdomen Explanation: When performing initial observations, the nurse would assess posture, body movements (for abnormalities and asymmetry), nutritional status, speech pattern and vital signs, including auscultation of blood pressure. Lung percussion and abdominal palpation are done later in the assessment.
The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information? "1) Are you only able to breathe when you are sitting upright?" 2) "How far can you walk without becoming short of breath?" 3) "Are you coughing up blood at night?" 4) "Are you urinating excessively at night?"
Correct response: "Are you only able to breathe when you are sitting upright?" Explanation: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. When teaching the client about nitroglycerin administration, which instruction should the nurse provide? 1) "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." 2) "Replace leftover sublingual nitroglycerin tablets every 9 months to make sure your pills are fresh." 3) "A burning sensation after administration indicates that the nitroglycerin tablets are potent." 4) "You may take a sublingual nitroglycerin tablet every 30 minutes, if needed. You may take as many as four doses."
Correct response: "Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.
The nurse has closed the interview with the client and observes that the client appears to have something else to say. What statement made by the nurse can provide an opportunity for the client to express concerns and ask questions? 1) "Use your call bell if you need anything." 2) "I don't know what else I could tell you, this about covers all of it." 3) "Well that is all I have for you. Let me know if you need anything." 4) "Do you have any questions or concerns that we have not discussed."
Correct response: "Do you have any questions or concerns that we have not discussed." Explanation: Asking if the client needs more information provides an opportunity for the client to express concerns and ask questions. Instructions about the call bell do not allow the client to ask questions and is not specific for questions or concerns. "I don't know what else I could tell you" inhibits the client from asking the nurse anything further as well as "Well that is all I have for you."
Which statement by the nurse reflects the nurse's attempt to establish rapport and reduce patient anxiety? 1) "Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip." 2) "Bill, I have adjusted the room temperature to keep you comfortable during your assessment." 3) "Bill, I know the physical assessment takes a long time to complete; I will allow you a 10-minute break following the respiratory assessment." 4) "Mr. Jones, I need to stand at the computer to record your responses to the questions accurately during the assessment interview."
Correct response: "Good morning, Mr. Jones. The last time you were here you were planning a vacation. Tell me about your trip." Explanation: Effective communication promotes respect and trust and reduces client anxiety. The nurse should start by establishing rapport with the client and family members. Inquiring about the client's family, jobs, or interest helps place the client at ease and may build rapport. Rapport is facilitated by making eye contact. During the introduction, the nurse should address the client by his or her surname. The nurse should avoid tiring older clients by allowing rest periods during the physical examination; however, this is not the most important aspect of establishing a rapport with the client. Ensuring that the client is comfortable by keeping the room warm and free from drafts is important during the interview, but does not necessarily help to build rapport.
The nurse is ending an interview with a client who has been admitted to the hospital for pneumonia. What statement made by the nurse would be an effective way to end the interview? 1) "I appreciate your cooperation and understand that your symptoms have been getting worse for 2 days." 2) "I will refer any questions you have to the physician." 3) "How long do you think you will be in the hospital for pneumonia?" 4) "Let me show you where your call bell, television controls, and bathroom are."
Correct response: "I appreciate your cooperation and understand that your symptoms have been getting worse for 2 days." Explanation: An effective way of ending the interview is to summarize what occurred and thank the client for cooperating. Referring questions to the physician without attempting to answer any is not an effective means of communication and does not end the summary phase adequately, and the client has not been thanked for cooperating. A question is not a summarization. The orientation of the client's room is not related to the interview.
A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is removed at bedtime. Which is the best response by the nurse? 1) "Nitroglycerine causes headaches, but removing the patch decreases the incidence." 2) "You do not need the effects of nitroglycerine while you sleep." 3) "Removing the patch at night prevents drug tolerance while keeping the benefits." 4) "Contact dermatitis and skin irritations are common when the patch remains on all day."
Correct response: "Removing the patch at night prevents drug tolerance while keeping the benefits." Explanation: Tolerance to antianginal effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse effects of nitroglycerin are headaches and contact dermatitis but not the reason for removing the patch at night. It is true that while the client rests, there is less demand on the heart but not the primary reason for removing the patch.
A client was brought to the Emergency Department with elevated temperature of three days' duration and malaise. During the interview, which type of question is the most helpful? 1) "Where is your pain?" 2) "Are you in pain?" 3) "Have you had this pain previously?" 4) None of the options is correct.
Correct response: "Where is your pain?" Explanation: Questions are best phrased as "open-ended" questions that require discussion rather than "closed" questions that require only "yes" or "no" answers.
The client with valvular disorder is ordered a preoperative dose of penicillin G 600,000 units to be given IV q4h. Penicillin G is supplied in a vial labeled as, "Add 4 mL diluent to yield 250,000 units per mL." How many milliliters will the nurse need to withdraw from the vial to provide the ordered dose? ______________mL
Correct response: 2.4 Explanation: 600,000 units/250,000 units= 2.4 mL
The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tells the nurse that she is afraid of dying while undergoing the surgery. The nurse should be aware that: 1) A further assessment of anxiety is required. 2) A more complete physical examination is required. 3) Preoperative fears are normal and will be alleviated with time. 4) Teaching should be initiated immediately to alleviate the fears.
Correct response: A further assessment of anxiety is required Explanation: An assessment of anxiety levels is required in the patient to assist in identifying fears and developing coping mechanisms for those fears. If anxiety is high, it may interfere with teaching, and surgical outcome is poor. Nothing in the scenario suggests that a more complete physical examination is required. Further assessment should precede teaching. Preoperative fears are normal, but they should not be ignored and will not necessarily abate on their own.
The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently? 1) Airway patency 2) Level of consciousness 3) Psychological status 4) Pain level
Correct response: Airway patency Explanation: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis? 1) Apply a moustache dressing. 2) Provide a nasal splint. 3) Apply direct continuous pressure. 4) Place the client in a semi-Fowler's position.
Correct response: Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks? 1) Preparing the patient for a septoplasty 2) Applying nasal packing 3) Administering nasal lavage 4) Applying steroidal nasal spray
Correct response: Applying nasal packing Explanation: A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.
A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease? 1) Assess chest pain and administer prescribed drugs and oxygen 2) Assess blood pressure and administer aspirin 3) It is not important to assess the client or to notify the physician 4) Assess the client's physical history
Correct response: Assess chest pain and administer prescribed drugs and oxygen Explanation: The nurse assesses the client for chest pain and administers the prescribed drugs that dilate the coronary arteries. The nurse administers oxygen to improve the oxygen supply to the heart. Assessing blood pressure or the client's physical history does not clearly indicate that the client has CAD. The nurse does not administer aspirin without a prescription from the physician.
A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? 1) Assess the client's level of pain and administer prescribed analgesics. 2) Assess the client's level of anxiety and provide emotional support. 3) Prepare the client for pulmonary artery catheterization. 4) Ensure that the client's family is kept informed of the client's status.
Correct response: Assess the client's level of pain and administer prescribed analgesics. Explanation: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and family members should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.
The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? 1) Assessment of body image 2) Assessment of jugular venous pressure 3) Assessment of carotid pulse 4) Assessment of swallowing ability
Correct response: Assessment of swallowing ability Explanation: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client's body image should be assessed, but dysphagia has the potential to affect the client's airway, and is a consequent priority.
The LPN is transferring a medical client to the intensive care unit and is met by the RN. The RN is listening with the stethoscope to determine how much fluid the client may have in the lungs. What type of assessment technique is the RN performing? 1) Inspection 2) Palpation 3) Percussion 4) Auscultation
Correct response: Auscultation Explanation: Auscultation means listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries. Inspection is the visual observation of the client and specific structures. Palpation is the touching of the patient with the fingertips or hands. Percussion is tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse? 1) Administer epinephrine 1:10,000 10 mL IV push. 2) Deliver breaths with a bag-valve mask. 3) Defibrillate the patient with 360 joules. 4) Call for help and begin chest compressions.
Correct response: Call for help and begin chest compressions. Explanation: Following the recognition of unresponsiveness, a protocol for basic life support is initiated. This includes activation of the emergency response team for help and performance of high-quality cardiopulmonary resuscitation (CPR), which includes beginning chest compressions.
When taking a health history, which of the following would most likely be the primary source of information? 1) Patient's spouse 2) Client 3) Referring physician 4) Medical record
Correct response: Client Explanation: In most instances, the client is the informant unless the client is developmentally delayed, mentally impaired, disoriented, confused, unconscious, or comatose. In these cases, another individual close to the client would provide the necessary information. The nurse could collect additional data from the referring physician and the medical record, but these would not be the primary sources of information.
Which assessment parameter is important for the client diagnosed with congestive heart failure? 1) Distended veins 2) Crepitus 3) Excess tears 4) Photosensitivity
Correct response: Distended veins Explanation: During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate, counts radial heart rate, measures BP, checks for distended neck veins, and documents any signs of peripheral edema, lethargy, or confusion. The nurse need not examine joints for crepitus, eyes for excess tearing, or signs of photosensitivity because these are not symptoms of congestive heart failure.
For a client with pleural effusion, what does chest percussion over the involved area reveal? 1) Absent breath sounds 2) Dullness over the involved area 3) Friction rub 4) Fluid presence
Correct response: Dullness over the involved area Explanation: Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.
What would be important for the nurse to consider at the beginning of an interview? 1) Establish rapport with the client and family members 2) Keep the room a comfortable temperature for the nurse 3) Allow rest during the interview 4) Address the client by his or her first name
Correct response: Establish rapport with the client and family members Explanation: During the interview process, the nurse should start by establishing rapport with the client and family members and ensuring that the client is comfortable. During the introduction, the nurse should address the client by his or her surname. The nurse should avoid tiring older clients by allowing rest periods during the physical examination and should keep the room at a comfortable temperature for the client.
Which particular area(s) should be examined to assess peripheral edema? 1) Upper arms 2) Under the sacrum 3) Lips, earlobes 4) Feet, ankles
Correct response: Feet, ankles Explanation: When right-sided heart failure occurs, blood accumulates in the vessels and backs up in peripheral veins, and the extra fluid enters the tissues. Particular areas for examination are the dependent parts of the body, such as the feet and ankles. Other prominent areas prone to edema are the fingers, hands, and over the sacrum. Cyanosis can be detected by noting color changes in the lips and earlobes.
A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: 1) Fever 2) Headache 3) Myalgias 4) Nausea
Correct response: Fever Explanation: The signs and symptoms described are consistent with acute pharyngitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.
The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? 1) Hoarseness 2) Dyspnea 3) Dysphagia 4) Alopecia
Correct response: Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
The nurse instructs the client with heart failure to weigh themselves at the same time each day using the same scale. When should the client contact the physician? 1) If the weight gain is more than 3 lb in 1 week. 2) If the weight gain is more than 4 lb in 1 month. 3) If the weight gain is more than 2 lb in 24 hours. 4) If the weight gain is more than 1 lb in 48 hours.
Correct response: If the weight gain is more than 2 lb in 24 hours. Explanation: Check weight at the same time each day using the same scale: consult a physician if the client gains more than 2 pounds in 24 hours. The other distractors are not correct since there is a variance with weight on a daily basis.
The nurse is conducting an interview with a client at the hospital. The client has a roommate in the room. Where would the optimal place for this interview take place? 1) In the waiting area 2) In the client's room 3) In a private treatment room 4) At the nurse's station
Correct response: In a private treatment room Explanation: A private setting for the interview is essential to eliminate interruptions and maintain the client's confidentiality. The nurse should explain that information obtained during the interview helps with planning care and is kept confidential, although all members of the healthcare team share the data. The other settings are not private, and information may be overheard.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? 1) Initiate oxygen therapy. 2) Administer a heparin bolus and begin an infusion at 500 units/hour. 3) Administer analgesics as ordered. 4) Perform nasopharyngeal suctioning.
Correct response: Initiate oxygen therapy. Explanation: The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
When preparing to perform a physical assessment of a patient, the nurse performs the steps below. Place the steps in the order in which they most typically are completed. Inspection Palpation Percussion Auscultation
Correct response: Inspection Palpation Percussion Auscultation Explanation: The traditional sequence of steps for the physical examination is inspection, palpation, percussion, and auscultation, except in the case of the abdominal examination, when auscultation is performed before palpation and percussion to avoid altering bowel sounds.
A nurse is conducting a health assessment and interviewing a patient. Which of the following would be MOST appropriate for the nurse to do? 1) Avoid making direct eye contact with the patient. 2) Refrain from asking sensitive questions. 3) Use technical terms to describe the patient's condition. 4) Listen carefully to the patient's responses.
Correct response: Listen carefully to the patient's responses. Explanation: When communicating with a patient during a health history, it is important for the nurse to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient's responses. Technical terms should be avoided. The health history involves asking questions about sensitive issues such as sexuality. As such, the nurse needs to develop trust and rapport with the patient and approach the topic with sensitivity, using an orienting question or statement to begin the discussion.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? 1) Pain in the feet 2) Coolness to lower extremities 3) Decreased urinary output 4) Localized calf tenderness
Correct response: Localized calf tenderness Explanation: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.
Which nursing measure should be considered when performing a physical examination of a client using the inspection technique? 1) Ensure that the client's family member is present. 2) Provide a cool room for examination. 3) Maintain standard precautions. 4) Dim overhead lights.
Correct response: Maintain standard precautions. Explanation: The nurse should provide a warm room for the examination and maintain standard precautions. It is not essential for the patient's family member to be present during the physical examination. The nurse should also maintain the patient's privacy. Dimming the lighting will decrease the nurse's ability to perform an adequate inspection.
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? 1) Dyspnea 2) Orthopnea 3) Hemoptysis 4) Hypoxemia
Correct response: Orthopnea Explanation: Orthopnea is the term used to describe a client's inability to breathe easily except in an upright position. Orthopnea may occur in clients with heart disease and, occasionally, in clients with COPD. Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? 1) Paradoxical chest movement 2) Cyanosis 3) Hypertension 4) Wheezing
Correct response: Paradoxical chest movement Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. Upon expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the client's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
While performing the physical examination, the nurse determines that a patient has an area of consolidation in the lungs suggesting pneumonia. Which technique would the nurse most likely have used to obtain this finding? 1) Inspection 2) Palpation 3) Percussion 4) Auscultation
Correct response: Percussion Explanation: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. It also can be used to locate a consolidated area caused by pneumonia. Inspection reveals characteristics such as color, lesions, edema, symmetry, and pulsations. Palpation is used to examine body structures not visible. Auscultation reveals sounds created by the movement of air or fluid. With pneumonia, lung sounds may be altered as the air moves through the consolidated area.
When asking questions about the client's marital status, the nurse is gathering information about which of the following? 1) Present illness 2) Functional assessment 3) Chief complaint 4) Psychosocial history
Correct response: Psychosocial history Explanation: The psychosocial history and cultural history include the client's age, occupation, religious affiliation, cultural background, health beliefs, marital status, and home and working environments. When gathering information about the history of the present illness, the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A functional assessment determines how well the client can perform activities of daily living. The chief complaint is the current reason the client is seeking care.
A client with history of COPD, is admitted to the unit. As the LPN/LVN completes the first portion of the database interview, the nurse chooses to auscultate lung sounds as the client's respiratory distress increased during the interview. After auscultation, what is the LPN/LVN's next step? 1) Report the client's increased respiratory distress to the RN for immediate assessment. 2) Continue the assessment until complete. 3) Complete the paperwork, then continue the assessment. 4) Call the physician with the client's increased respiratory rate after completing the assessment.
Correct response: Report the client's increased respiratory distress to the RN for immediate assessment. Explanation: Since an increase in respiratory distress can be life threatening, it should be reported to the RN immediately.
A client who has an altered level of consciousness is receiving tube feedings. Clients receiving tube feeding should be placed in which position? 1) Side-lying 2) Supine 3) Trendelenburg 4) Semi-Fowler's or higher
Correct response: Semi-Fowler's or higher Explanation: Clients receiving tube feedings are positioned with the head of the bed at 30 degrees or higher during feedings and for 30 to 45 minutes after tube feedings. Clients receiving oral feedings are positioned with the head of the bed in an upright position for 30 to 45 minutes after feedings. For clients with a nasogastric or gastrostomy tube, the placement of the tube and residual gastric volume must be checked before each feeding.
Which of the following is important to do at the end of an interview with the client? 1) Call the client's family members to give them information. 2) Call the physician to discuss findings and establish a plan of care. 3) Conduct a physical examination immediately after the interview. 4) Summarize the information and thank the client for cooperating.
Correct response: Summarize the information and thank the client for cooperating. Explanation: A nurse should end an interview with the client by summarizing what occurred and thanking the client for cooperating. The nurse should not discuss the information obtained through the interview with the client's family. It may not be necessary to call the doctor for further consultation or to conduct a physical examination immediately after the interview.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? 1) The client says that he has been urinating less frequently at night. 2) The client says he has been hungry in the evening. 3) The client says his rings have become tight and are difficult to remove. 4) The client says he is short of breath when ambulating.
Correct response: The client says his rings have become tight and are difficult to remove. Explanation: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
Questions about current and past use of prescription medications would probably be part of which of the following? 1) The client's past health history 2) The client's history of present illness 3) The client's chief complaint 4) The functional assessment
Correct response: The client's past health history Explanation: The client's past health history includes identifying childhood diseases and prior hospitalizations. History of present illness is gathered when the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A chief complaint is the current reason the client is seeking care. A functional assessment determines how well the client can perform activities of daily living.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? 1) The system is functioning normally. 2) The patient has a pneumothorax. 3) The system has an air leak. 4) The chest tube is obstructed.
Correct response: The system has an air leak. Explanation: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
During the initial physical examination, a client's pulse rate was 71 beats per minute (bpm). Four hours later on reassessment, the pulse rate was 40 bpm. How should the nurse proceed? 1) Have the client get up and walk around the room; then take another pulse. 2) Call for the crash cart just in case. 3) Thoroughly assess the client; then notify the physician. 4) Attach the client to a heart monitor.
Correct response: Thoroughly assess the client; then notify the physician. Explanation: The ability to assess a client accurately is an integral nursing skill. The nurse will use appropriate assessment skills to identify psychological problems. Unexpected changes and values that deviate from a client's normal value are to be brought to the attention of the physician.
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall? 1) Turn onto the affected side. 2) Use a prescribed analgesic. 3) Avoid using a pillow while splinting. 4) Use a heat or cold application.
Correct response: Turn onto the affected side. Explanation: The nurse teaches the client to splint the chest wall by turning onto the affected side. The nurse also instructs the client to take analgesic medications as prescribed and to use heat or cold applications to manage pain with inspiration. The client can also splint the chest wall with a pillow when coughing.
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? 1) Rhonchi 2) Crackles 3) Wheezes 4) Pleural friction rub
Correct response: Wheezes Explanation: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.
Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers? 1) Observe for symptoms of pulmonary edema. 2) Continue the drug and document in the client's chart. 3) Withhold the drug and inform the primary health care provider. 4) Check for signs of toxicity.
Correct response: Withhold the drug and inform the primary health care provider. Explanation: Before administering a beta-blocker, the nurse should monitor the client's apical pulse. If the heart rate is less than 60 bpm, the nurse should withhold the drug and inform the primary health care provider.
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? 1) Administer the medication and inform the charge nurse about the rate. 2) Withhold the medication and notify the physician of the heart rate. 3) Administer atropine to speed the heart rate and then administer the digoxin. 4) Administer the medications and then notify the physician.
Correct response: Withhold the medication and notify the physician of the heart rate. Explanation: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a physician is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.
A 68-year-old client was admitted after a fall at home. The client reports feeling dizzy before falling and reports a history of diabetes mellitus. The client's preliminary lab results indicate blood glucose of 51. The client also reported feeling quite hungry the entire morning before falling. Which data is objective? 1) blood glucose 2) dizziness 3) hunger 4) None of the options is correct.
Correct response: blood glucose Explanation: Objective data (also known as signs) are facts obtained through observation, physical examination, and diagnostic testing that are measurable (blood pressure, heart rate, lab results, etc.).
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows 1) redness and induration. 2) drainage. 3) tissue sloughing. 4) bruising.
Correct response: redness and induration. Explanation: The injection site is inspected for redness and palpated for hardening. Drainage at the injection site does not indicate a reaction to the tubercle bacillus. Sloughing of tissue at the injection site does not indicate a reaction to the tubercle bacillus. Bruising of tissue at the site may occur from the injection but does not indicate a reaction to the tubercle bacillus.