ATI physical assessment and Nursing process (Test 2)

A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include?

"Insert the earpieces at a downward angle toward your nose" The nurse should insert the earpieces at a downward angle toward their nose because this helps ensure that sounds are effectively transmitted to their eardrums.

A nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultation the apical pulse at which of the following precordial landmarks?

Left of the midclavicular line at the fourth intercostal space

A nurse is inspecting 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 performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect?

A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should be performed when you are preparing to auscultate the apical pulse.

A nurse is implementing priority based interventions for a group of clients. Which of the following clients should the nurse see first?

A client who has a cast on a compound fracture and has SaO2 of 88% When using the airway, breathing, circulation approach to client care, the nurse should determine that the finding of SaO2 of 88% indicates hypoxia and requires priority-based interventions.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.

A. Reassess the client to determine the reasons for inadequate pain relief

A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality?

Ability of staff to access electronic health records of clients throughout the facility

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 top of the nurse's hand

A nurse is admitting a client who reports increased thirst and fatigue. Which of the following actions should the nurse include in the assessment step of the nursing process?

Ask the client when the condition started. Assessment is the first step of the nursing process, where the nurse gathers subjective and objective information about the client's condition.

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics?

Balance The nurse should explain that the Romberg test is the most common test of balance.

A nurse is performing a screening for scoliosis on a school age child. Which of the following instructions should the nurse provide?

Bend forward with your knees straight and your arms dangling

A nurse is caring for an older adult client who has an allergy to sulfa, Is taking valproic acid (Depacote) for a seizure disorder and has been newly diagnosed with osteoarthritis. The client states "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence the nurse should inform the client of which of the following?

Celecoxib is contraindicated in clients with an allergy to sulfonamide

A nurse is following the steps of the nursing process when caring for a group of clients. Which of the following actions by the nurse demonstrates the evaluation step of the nursing process?

Check and document a client's pain level 30 min after administering pain medication. The nurse is evaluating, which is the final step of the nursing process, to determine if the pain medication administered to the client is effective. Evaluation is the same as assessment; however, to determine the client's status and progress, evaluation is performed.

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first?

Develop a plan of care The first action the nurse should take using the nursing process is to assess the client and develop a plan of care. The nursing process follows the steps of assessment, analysis, planning, implementation, and evaluation.

A nurse is assessing a clients vascular status of the lower extremities. The nurse should place their fingertips on the top of the clients foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses?

Dorsal pedis

A nurse is inspecting the skin of a toddler. Which of the following findings should the nurse report to the provider?

Ecchymotic area on the abdomen

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the clients MAR and noted that the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?

Evaluation

A nurse is preparing to perform a physical examination on a ten year old child. Which of the following interventions should the nurse plan to implement?

Explain how the equipment works using the correct medical terminology

A nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which of the following components should the nurse identify as part of the planning step of the nursing process?

Formulate client goals for prioritized problem. Formulating client goals for prioritized problems is a component of planning, which is the third step in the nursing process.

A nurse is performing a complete head to toe physical exam for a client. Which of the following techniques should the nurse perform first?

Inspection

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills?

Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation. The nurse is using critical thinking when analyzing a client's critical issues and then planning to intervene with an appropriate action.

A nurse is performing 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 Kyphosis, a pronounced "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging. This pronounced convexity of the thoracic spine is also common in older clients who have had vertebral fractures.

A nurse is preparing to obtain a temperature on an 18 month old toddler during a well child exam. Which of the following actions should the nurse take?

Place the thermometer tip in the center of the toddlers Scilla against their skin

A nurse is assessing the reflexes of a 6 month old infant. Which of the following findings should the nurse expect?

Positive Babinski reflex

A nurse is palpating a tender area of the clients abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document?

Rebound tenderness The nurse should document that the client is experiencing rebound tenderness, which is an increase in pain when deep palpation over a tender area is released. Rebound tenderness in the right lower quadrant at McBurney's point (one third the distance from the anterior iliac crest to the umbilicus) is an indication of acute appendicitis.

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the clients abdomen should the nurse attempt to auscultate active bowel sounds first?

Right lower quadrant Evidence-based practice indicates that the first area the nurse should auscultate for active bowel sounds is over the right lower quadrant of the client's abdomen. The right lower quadrant is located to the right of the umbilicus and contains the ileocecal valve. This is where the small intestine connects to the large intestine, and it is normally very active with bowel sounds. For an average adult, the nurse should expect to hear 5 to 30 bowel sounds per minute.

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 charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? (Select all that apply)

Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Repositioning a client every 2 hr to reduce pressure injury risk

A nurse is performing an annual physical exam on an adolescent. Which of the following should the nurse include in the general survey?

The adolescent makes good eye contact

A nurse is assessing a clients cranial nerves. Which of the following client actions is an indication that the cranial nerve I is intact?

The client can identify a minty scent. Cranial nerve I, the olfactory nerve, controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee.

A nurse is performing a general client survey and finds that the client has a body mass index (BMI) of 23. Which of the following should the nurse document?

The client has a BMI within the expected reference range.

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the clients breathing. The nurse should identify this observation as which of the following findings?

crackles

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply)

respiratory rate is 22/min with even unlabored respirations the client's skin is pink, warm, and dry the assistive personnel reports that the client walked with a limp