EAQ 2

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary Edema

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?

Radial and apical pulse

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse?

Respiratory rate of 14 breaths/minuteBlood pressure of 120/80 mmHgOxygen saturation of 95%

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? SAP

Respiratory rate: 14. Blood pressure: 110/75. Oxygen saturation: 92%

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

When nurses are conducting health assessment interviews with older clients, what step should be included?

Spend time in several short sessions to elicit more complete information from the clients

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?

Subacute bacterial endocarditis

The RN is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning?

The client experiences recurrent episodes of binge eating

A registered nurse instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. What observations may have led to this conclusion? SAP

The client has a habit of breathing through his or her mouth The client ingested juice 20 minutes before his/her temperature was taken

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster?

The client reports pain with movement. The client has pain over the surgical area. The client rates the pain as 8 on a scale of 0 to 10.

A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7mm indurated area at the injection site. Which statement made by the nurse correctly describes this result?

The result indicates that you are infected with the tuberculosis organism

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities?

The student talks only to the interpreter about the patient.

While assessing a client who sustained a road traffic accident, a nurse notices that a client is unable to clench his teeth. Which cranial nerve might have been affected?

Trigeminal nerve

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning?

"I should examine the client in noise-free areas.""I should wear eye shields while examining a client with excessive drainage."

A nurse is teaching a client about proper hair hygiene and how to protect his or her hair from lice. Which statement made by the client indicates ineffective learning?

"I will soak the comb used to remove lice for 15 minutes in cold water."

A RN is supervising a student nurse while assessing a 70 year old client who is receiving amino glycoside therapy. Which statement about the client's condition requires correction?

"The client may have thinning of the tympanic membrane."

An older adult reporting a headache, nosebleed, and fatigue arrives at the hospital. The nurse instructs the nursing assistive personnel (NAP) to measure blood pressure using the one-step method. Arrange the sequence of events in order.

1.Place stethoscope earpieces in the ears and be sure the sounds are clear. 2.Relocate the brachial artery and place the bell or diaphragm chestpiece of the stethoscope over it. 3.Close the pressure bulb value and quickly inflate the cuff to 30 mm Hg above the client's systolic pressure. 4.Slowly release the pressure bulb valve and allow the needle of manometer gauge to fall at a rate of 2 to 3 mm Hg/sec. 5.Note the point on the manometer when you hear first clear sound. 6.Continue to deflate the cuff, noting the point at which muffled or dampened sound appears.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39 degrees Celsius. What is this temperature in Fahrenheit?

102.2

A client weighs 150 lb and is 5 feet 7 inches tall. What is this client's body mass index (BMI)?

23.53

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be?

33 degrees Celsius

A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect?

Aphasia

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have?

Ascites

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Assessment by the nurse was incomplete, and as a result the treatment was insufficient

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? SAP

Carotid Femoral

A client complains of chronically recurring ulcers on the lower leg. Upon assessment, a nurse finds the absence of hair growth on the legs and asks the client to consult the primary HCP immediately. Which condition does the nurse suspect?

Circulatory insufficiency

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as?

Contracture

Arrange in sequential order the steps taken by a nurse while assessing a client's visual field.

Direct the client to stand or sit 60 cm away from eye levelAsk the client to close his or her left or right eye gently and look directly at the nurse's opposite eyeClose the opposite eye to superimpose the field of visionMove a finger equidistant between the nurse and the client outside the field of visionAsk the client to report when he or she is able to see the finger

Which site should be monitored for a pulse to assess the status of circulation to the foot? SAP

Dorsalis pedis arteryPosterior tibial artery

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?

Expectoration of blood

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion?

Foreign bodies in the rectum, urethra, or vagina

What sound describes an inflamed pleura?

Frictional rub

A client has a hx of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed?

HIV infection

While assessing a client, the nurse finds bluish coloration of the skin. The nurse finds that this discoloration is due to cyanosis. Which condition may be suspected?

Heart disease

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

A nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions may be suspected in the older adult? SAP

Hyperopia Presbyopia

The nurse is performing a skin assessment of a client. Which findings in the client may indicate a risk of skin cancer? SAP

Lesion Lumps Rashes

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? SAP

Lips Mouth Nail beds

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

Loss of body weight

A nurse is assessing a client with the hx of marijuana use. Which long-term effects are associated with marijuana?

Lung cancer Emphysema Heart disease

While assessing a client, a nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. What could be the reason behind these sounds?

Muscular spasms in the larger airways

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? SAP

Older adult History of smoking Chronic lung disease

While auscultating the heart, a HCP notices S3 heart sounds in four clients. Which client is at more risk for heart failure?

Older adult client