FON Module 2 Ticket-To-Test

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention? "Does your skin condition keep you awake at night?" "Have you had any changes in your diet?" "How do you handle stress?" "How does your skin condition make you feel?"

"How do you handle stress?"

A nurse is working with a licensed practical nurse to care for a client who is receiving a continuous IV infusion. Which of the following findings reports by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? "The infusion rate has stopped but the tubing is not kinked" "The area surrounding the insertion site feels warm to the touch" "There is fluid leaking around the insertion site" "There is no blood return when the thing is aspirated"

"The area surrounding the insertion site feels warm to the touch"

A nurse is assessing a client for pitting edema and notes the indentation fo 6mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the clients edema? 4+ 3+ 2+ 1+

3+

A nurse is assessing a client's redial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? Assess the apical pulse for a full minute Assess the apical pulse with a Doppler device Assess the pedal pulses for a full minute Assess the pedal pulses with a doppler device

Assess the apical pulse for a full minute

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? Call the client's provider Assess the client Notify the nurse manager Complete an incident report

Assess the client

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? Planning Evaluation Assessment Implementation

Assessment

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? Pinnae of the ears Dorsal surface of the hand Conjunctivae Dorsal surface of the foot

Conjunctivae

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the clients breath. For which of the following findings should the nurse assess first? Client's history of previous accidents Date of the clients last tetanus immunization Clients blood alcohol level Signs of wound infection

Date of the clients last tetanus immunization

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? Reposition the client Administer the medication Determine the location of the pain Review the effects of pain medication

Determine the location of the pain

A nurse is completing a clients history and physical examination. Which of the following information should the nurse consider subjective data? Blood pressure Cyanosis Nausea Petechiae

Nausea

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take? Report the suspected abuse to the authorities Obtain a detailed history Ask a psychiatrist to talk with the parents Separate the child from the parents

Obtain a detailed history

A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an interventions should the nurse complete? Document dry, flaky skin as an expected finding Perform examination of the back before the general inspection of the skin Pinch up a fold of skin to check for turgor Use a penlight to examine the back in greater detail

Pinch up a fold of skin to check for turgor

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply) Poor skin turgor Bradycardia Hypotension Pale yellow urine Flat neck veins

Poor skin turgor Hypotension Flat neck veins

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply) Restlessness Grimacing Moaning Clenching Drowsiness

Restlessness Grimacing Clencing

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? Bradypnea Somnolence Pallor Tachycardia

Tachycardia

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? Vital sign measurement The clients self-report of pain severity Visual observation for nonverbal signs of pain The nature and invasiveness of the surgical procedure

The clients self-report of pain severity

A nurse is assessing a clients cardiovascular system. To palpate for unexpected pulsations int he pulmonic area, at which anatomical location should the nurse place her fingers? The left second intercostal space The right second intercostal space The left fifth intercostal space The left fifth intercostal space at the midclavicular line

The left second intercostal space

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? Crackles Rhonchi Stridor Wheezes

Wheezes

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? Vital signs Self-Report of pain Severity of the condition Nonverbal behavior

self-report of pain