ЁЯМ╕ATI HEALTH ASSESMEMT FINAL EXAMЁЯМ╕
A nurse is expecting the thorax of an infant. Which of the following findings should the nurse expect?
A barrel-shaped chest in which the anterior-posterior are equal
A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last?
Anus
A nurse is performing an abdominal examination on a preschooler. Which of the following actions should the nurse take during the assessment?
Ask the child to "help" with the exam by placing their hand on the top of the nurse"s hand
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure?
Bear down
Which of the following actions should the nurse instruct the client to perform during the insertion procedure?
Bear down
A nurse is evaluating a client for an alteration in orientation. Which of the following questions should the nurse asked the client?
Can you tell me what month it is ?
A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first?
Check the catheter for kinks
A nurse is expecting the skin of a toddler. Which of the following findings should the nurse report to the provider?
Ecchymotic area on the abdomen
A nurse is preparing to perform a physical examination on a 10 year old child. Which of the following intervention should the nurse plan to implement?
Explain how the equipment works using correct medical terminologies
A nurse is assessing a client upper extremities. Which of the following action should the nurse take?
Inspect the condition of each fingernail, compare the amplitude of the radical pulse bilaterally, palpate the shoulder, elbow, wrist and finger joints.
A nurse is performing an assessment of a client lower extremities. Which of the following action should the nurse include in this assessment?
Inspect the pattern of the hair distribution
You are performing an assessment of a client's eyes. Which of the following techniques and tools should you plan to use?
Inspection; Inspection is a visual examination. You would use this technique when examining the eyes.
A nurse is assessing a client neck. Which of the following action should the nurse ask the client to perform during this assessment?
Instruct the client to swallow, apply downward pressure, and ask the client to shrugged his shoulders, request the client move their head forward and backward, and then side to side.
A nurse is examining a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging?
Kyphosis
A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take?
Leave a space between the penis and sheath portion tip. The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.
A nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks?
Left of the midclavicular line at the fourth intercostal space
The nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks?
Left of the midclavicular line at the fourth intercostal space
A nurse is prepping to care for a group of clients in an acute care setting. Which of the following should the nurse plan to assess for every client?
Lung sounds, bowel sounds, pedal, pulses, mental status
A nurse is an outpatient setting is performing a head to toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?
Nutritional status, hygiene, posture
A nurse is performing an assessment of the head for a client who reports ear pain. Which of the following action should the nurse take?
Palpate the mastoid area for pain
A nurse is preparing to perform a head to toe assessment on a client. Which of the following tools should the nurse plan together?
Penlight, stethoscope, sphygmomanometer
A nurses is preparing to obtain a temperature on an 18 month old toddler during a well child examination. Which of the following action should the nurse take?
Place the thermometer tip in the center of the toddler's axilla against their skin
A nurse is assessing the reflexes of a six month old infant. Which of the following reflects findings should the nurse expect?
Positive Babinski reflex
A nurse is assessing a client radical pulse rate. Which of the following information should the nurse collect while performing this action?
Regularity of the pulse, strength of the pulse
A nurse is obtaining the blood pressure of a school age child. Which of the following actions should the nurse take?
Select a cuff width that covers 40% of the upper arm
A nurse is performing an annual physical examination on an adolescent. Which of the following should the nurse include in the general survey?
The adolescent makes good eye contact
A nurse is planning to complete a physical assessment of a client. Which of the following action should the nurse plan to take?
Use quotation marks when documenting client's statements.
A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take. (Move the steps of the process into the box on the right, placing them in the selected order of performance. All steps must be used.)
Wipe the port with an alcohol swab or agency specified antiseptic is the first step. The nurse should wipe the port with an alcohol swab to decrease the amount of bacteria present. Attach a syringe to the collection port of the indwelling catheter is the second step. Attaching a syringe after disinfecting the port allows for withdrawal of the urine specimen. Withdraw 3 to 30 mL of urine is the third step. The amount of urine withdrawn will depend on the laboratory test prescribed. Transfer the urine to a sterile specimen container is the fourth step. While transferring the urine specimen to the sterile specimen container, the nurse should be careful not to touch the syringe to the outside of the container. This might result in contamination of the specimen, which could cause an incorrect diagnosis. Transport the specimen to the laboratory is the fifth step. Transporting the specimen to the laboratory is the last step in the process. The specimen should not be allowed to sit at room temperature. If the specimen cannot be immediately transported to the lab, the nurse should store the specimen according to laboratory policy.
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization?
a client who is in the ICU for gastrointestinal bleed
A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take?
deflate the balloon completely before removal
A nurse is performing a screen for scoliosis on a school age child. Which of the following instruction should the nurse provide?
"Bent forward with your knees straight and your arms dangling"
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?
Lift the penis perpendicular to the body.
