UNIT 2

List in order of priority the techniques the nurse would use to assess a childs abdomen w/suspected appendicitis

-Ask where it hurts -Visually examine the abdomen -Warm the stethoscopes diaphragm -Auscultate for bowel sounds -Assess the abdomen by touch

A client is hospitalized w/pressure injuries. Which tasks could be delegated to an unlicensed assistive personnel (UAP)?

-Empty wound drainage containers -Report changes in wound apperance

Blood glucose levels identified as hypoglycemia?

68 mg/dL

Which term would the nurse use to describe a noticeable difference in the pupil sizes?

Anisocoria

When performing a focused respiratory assessment, which action would the nurse take first?

Check for any evidence of respiratory distress

A client reports right hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

Conduction hearing loss

The nurse assesses the lungs of a client & auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?

Crackles

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

Decreased sounds

Which factor in a clients health history increases the risk of hearing loss?

Diabetes Noisy environment Ear infections Loud music

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?

Diminished breath sounds on auscultation

The nurse reviews the medical record of a client w/ascites. Which client condition is a contributing factor to the development of ascites?

Diminished plasma protein level

Peritonitis develops in a client who had surgery for a ruptured appendix. Which clinical findings related to peritonitis should the nurse expect the client to exhibit?

Fever Abdominal muscle rigidity

Which client has inflamed pleura?

Friction rub

Which clients assessment findings indicate Cheyne-stokes respiration?

Irregular, alternating apnea & hyperventilation

What diagnosis would cause the nurse to assess for signs & symptoms of hypoglycemia?

Liver failure

Which structure is a component of the auditory ossicles?

Malleus

The nurse is caring for a 9 year old child in the postanesthesia care unit after craniotomy for the removal of an astrocytoma. Which intervention would the nurse perform when the childs right pupil suddenly dilates?

Notify the health care provider

When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find?

Oliguria Hypotension Tenting skin tugor

The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?

Pain in the RLQ

Which finding would the nurse expect when assessing a client with left sided pleural effusion?

Reduced or absent breath sounds at the left base of the lung

Which assessment would be the highest priority for the nurse to perform who has received sedative & opioid medications postoperatively?

Respiratory

Which action would the nurse take to evaluate whether interventions have been effective in treating a clients exertional dyspnea?

Ask client about shortness of breath w/various activities

Which priority action would the nurse perform when caring for a client with suspected anaphylaxis?

Assess airway & oxygen

Which action will the nurse take after shopping the antibiotic infusion of a client who becomes restless & flushed, & begins to wheeze during the administration of an antibiotic?

Assess the clients respiratory status

Which cranial nerve would the nurse suspect is affected when a client reports buzzing in the ear for the past 5 days & a decreased ability to hear sounds while receiving long term amino-glycoside therapy?

CN V111 Vestibulocochlear

The nurse is caring for a client with emphysema. During assessment, the nurse would expect to auscultate which type of breath sounds?

Dminished breath sounds

Which finding would the nurse expect when assessing an older adult w/hearing loss secondary to aging?

Dry cerumen Difficulty hearing high pitched voices

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?

Elevated intraocular pressure

Which actions will the nurse take after noticing bibasilar crackles in a client who had an open cholecystectomy on the previous day?

Encourage turning, coughing, & deep breathing exercises Perform frequent breath sound assessment

The nurse is performing an assessment & notes that the client has exophthalmos & complains of double vision. These assessment findings are consistent with which condition?

Hyperthyroidism

A client appears anxious, exhibiting 40 shallow respirations per minute. The client reports dizziness, light-headedness, & tingling sensations of the fingertips & around the lips. The nurse concludes that the clients symptoms are most likely related to which condition?

Hyperventilation

A client with jaundice associated w/hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?

Inability of the liver to remove normal amounts of bilirubin from the blood

Which assessment finding would the nurse document in the clients health record as a positive Romberg test?

Inability to stand w/feet together when eyes are closed

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries?

Incontinence; inability to move independently

Which condition would the nurse suspect in a 6 year old child who was admitted w/abdominal pain, guarding, nausea, anorexia, and pain w/palpation of the RLQ?

Inflamed appendix

Which condition would the nurse suspect when a clients respiratory rate increases & the respirations are abnormally deep & regular?

Kussmauls respiration

When pressing to assess the 4 abdominal quadrants of a client who reports stomach pain, when would the nurse assess the symptomatic quadrant?

LAST

A client reports nausea, dyspnea, & RUQP unrelieved by antacids. The pain occurs most often after eating ground beef, sausage, or hot dogs. Which diet would the nurse instruct the client to follow?

LOW FAT

A client suffers hypoxia & a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best sites to assess this condition?

Lips, mouth, nail beds

Which assessment would be the most accurate method of monitoring the hydration status of a 2 month old infant admitted w/diarrhea & dehydration?

Obtaining daily weights

The nurse is caring for a client with a history of alcoholism & cirrhosis who is hospitalized w/severe dyspnea as a result of ascites. An increase in which process most likely caused the ascites?

Pressure in the portal vein

Which term would the nurse use to document a client with drooping of the eyelid over the pupil?

Ptosis

Which is the correct technique when using an otoscope to examine the ears of an infant?

Pull pinna down & back

Which action would the nurse take to obtain subjective data about a clients respiratory status?

Question the client about SOB & ask the client about color & quality of sputum

A client is admitted with an acute onset of RLQ pain at McBurney point, & appendicitis is suspected. For which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis?

Rebound tenderness

An auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss?

Speech therapy & hearing aids may be required

Which stage would the nurse document for a client with a pressure injury that has exposed bone & tendons?

Stage IV

Which intervention would the nurse use first for a client with the diagnosis of Guillian-Barre syndrome who is having difficulty expectorating respiratory secretions?

Suction the clients oropharynx

A postoperative client w/a tracheostomy tube in place suddenly develops noisy, increased respirations & elevated HR. The nurse would take which action immediately?

Suction the tracheostomy

Which rationale supports the nursing intervention to turn the client w/paraplegia every 1-2 hours?

To prevent development of pressure injuries

When providing care for several clients on a medical/surgical unit, which task would the nurse appropriately delegate to the unlicensed assistive personnel?

Turn a bed-bound client to prevent pressure injuries

When auscultating a clients chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?

Vesicular breath sounds

Which vitamin would the nurse anticipate may be needed when. a client with liver dysfunction reports bleeding gums & the nurse observes small facial hemorrhagic lesions?

Vitamin K

Which test helps primary health care provider distinguish between conductive & sensorineural hearing loss?

Weber test

Which finding in a client w/asthma exacerbation requires the most rapid action by the nurse?

Markedly decreased breath sounds

Which body system would the nurse assess in a client with human immunodeficiency virus HIV when inquiring about papillederma & the presence of exudates?

Ocular

The nurse is assessing female clients & identifies that which client has the greatest risk of developing gallbladder disease?

Older than 40 & obese

While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system might be affected in this client?

Semicircular canal

Which client would the nurse anticipate to have decreased skin tugor?

Severe dehydration

The nurse is caring for a client w/cholelithiasis. Which clinical manifestation would the nurse expect if the client develops obstructive jaundice?

Yellow sclera

Which finding in the clients history will alert the nurse to the most likely cause of the sensorineural hearing loss?

Prolonged exposure to noise

The nurse pulls up on the clients skin & releases it to determine whether the skin returns immediately to its original position. Which parameter is the nurse assessing?

Skin tugor

The nurse performs a respiratory assessment & auscultates high pitched, creaking, & accentuated breath sounds on expiration. Which term describes the findings?

Wheezes

After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding would confirm the clients diagnosis as presbyopia?

Loss elasticity of the lens

The nurse is providing care to a client with ascites secondary t liver failure. Which intervention is appropriate to include in the clients care?

Low sodium diet Daily abdominal girth measurements Daily weights