Fundamentals of Nursing Exam 3

The nurse performing a physical assessment is preparing to auscultate the client's breath sounds. Where would the nurse place the stethoscope to assess the bronchovesicular sounds? 1. Lower left lobe 2. Bottom of the trachea 3. Left upper lobe 4. Middle trachea

2 Rationale: Bronchovesicular breath sounds are heard over the main bronchi. Specifically, their normal location is between the first and second intercostal spaces at the sternal border anteriorly and posteriorly at T4 medial to the scapula. These sounds are moderate in pitch and medium in intensity, and the durations of inspiration and expiration are equal. Bronchial breath sounds are heard over the trachea. Vesicular breath sounds are heard over the lesser bronchi, the bronchioles, and the lobes.

The nurse can best assess for the presence of pallor in a dark-skinned client by focusing on which area? 1. Nail beds 2. Fingertips 3. Buccal mucosa 4. Palms of hands

3 Rationale: Pallor is best seen in the buccal mucosa or conjunctivae, particularly in dark-skinned clients. Cyanosis is best seen in the nail beds, conjunctivae, or oral mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.

A nurse is monitoring a client's food intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake?

660 Rationale: 8 oz + 10 oz + 4 oz = 22 oz Step 1: what is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X 1 oz/30 mL = 22 oz/X mL X = 660 mL Step 3: Round if necessary Step 4: Reassess to determine if the conversion to mL makes sense If 1 oz = 30 mL, then 22 oz = 660 mL

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period?

770 mL Rationale: Step 1: What is the unit of measurement the nurse should calculate? Step 2: Set up an equation and solve for x. 1 tsp/5 mL=2 tsp/X mL X=10 Step 3: Round if necessary. Step 4: Determine if the conversion to mL makes sense. If 1 tsp=5 mL, then 2 tsp=10 mL. Follow these steps for the conversions of oz to mL: Step 1: What unit of measurement should the nurse calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL=2 oz/X mL x=60 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz=30 mL, then 2 oz=60 mL. For the total intake, calculate: 350 mL + 200 mL + 150 mL + 10 mL +60 mL = 770 mL

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr shift?

90 mL Rationale: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 3 x 1 oz/X mL 1 oz/30 mL = 3 oz/X mL X=90 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. if 1 oz = 30 mL, then 3 oz = 90 mL.

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? a. 2 mm b. 4 mm c. 6 mm d. 8 mm

a Rationale: 1+ pedal edema = 2mm indentation 2+ pedal edema = 4mm indentation 3+ pedal edema = 6mm indentation 4+ pedal edema = 8mm indentation

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? a. Romberg b. Kinesthetic sensation c. 2-point discrimination d. Weber

a Rationale: A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test.

A nurse is using the Braden Scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? a. Incontinence b. Mental state c. Nutrition d. General physical condition

c Rationale: Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? a. Sugar b. Coffee c. Cotton wisps d. Snellen chart

c Rationale: The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve V, the nurse should ask the client to clench the teeth.

A nurse in a provider's office assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? a. Sunken eyeballs b. Hypotension c. Poor skin turgor d. Bounding pulse

d Rationale: A bounding pulse is an expected finding of fluid volume excess. All other options are clinical manifestations of fluid volume deficit.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? a. Audible check b. Murmur c. Third heart sound d. Pericardial friction rub

d Rationale: A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sounds that is heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems like rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward.

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? a. "Did you report the chest pain episodes to your physician?" b. "Is there a history of heart disease in your family?" c. "Have you had this pain before?" d. "Can you tell me what the pain felt like and show me exactly where it was?"

d Rationale: Using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority question for evaluating the client's pain is to quantify its characteristics, onset, duration, surrounding events, and location. This will help the nurse determine what action to take next.

The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)? 1. Mild drowsiness 2. Unilateral ptosis 3. Diminished mental acuity 4. Less frequent spontaneous speech

2 Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve. The remaining options identify signs of deteriorating level of consciousness.

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? a. Inspect both breasts simultaneously b. Squeeze the nipples c. Palpate the breast and tail of Spence d. Palpate the axillary lymph nodes

a Rationale: According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling.

The nurse is performing a cardiovascular assessment on a client with heart failure. Which item would the nurse assess to obtain the best information about the client's left-sided heart function? 1. the status of breath sounds 2. The presence of peripheral edema 3. the presence of hepatojugular reflux 4. the presence of jugular vein distention

1 Rationale: The client with heart failure may present different symptoms depending on whether the right or left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.

The nurse preceptor is orienting a newly hired registered nurse (RN) in an outpatient clinic. The newly hired RN is performing an otoscopic examination on an adult client. Which observation indicates to the preceptor that the newly hired RN is implementing the correct procedure? 1. Pulls the pinna up and back to assist in inserting the speculum 2. Pulls the earlobe down and back to assist in inserting the speculum 3. Tilts the client's head forward and down before inserting the speculum 4. Obtains a small speculum to decrease the discomfort of the examination

1 Rationale: The correct procedure for preforming the otoscopic examination on an adult is to pull the pinna up and back and to visualize the external canal while slowly inserting the speculum. Pulling the pinna down and back would be appropriate for assessing a child less than 3 years old. The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. A small speculum may not provide adequate visualization of the ear canal and would be more appropriately used in a pediatric setting.

During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client has a need for further teaching regarding TSE? 1. "I know to report all small lumps." 2. "I should examine myself every 2 months." 3. I should examine myself after I take a warm shower." 4. "I know it's not normal to feel something that is cord-like in the back."

2 Rationale: TSE should be performed every month. Small lumps or abnormalities should be reported. The spermatic cord finding is normal. After a warm bath or shower, the scrotum is relaxed, which makes it easier to perform TSE.

The nurse is reviewing the findings of a physical examination that are documented in a client's record. The nurse notes which documented finding as subjective data? Select all that apply. 1. Client's left eyelid droops 2. Client reports feeling very tired 3. Client's father had diabetes mellitus 4. Client has an allergy to acetylsalicylic acid 5. Client's vital signs are all within normal limits.

2, 3, 4 Rationale: Subjective data collected during the health history, are information that the client says about herself or himself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and the laboratory study and diagnostic test results.

The nurse is assessing a client for a pericardial friction rub. Which action by the nurse indicates the best method in assessing for this abnormality? 1. Placing the bell of the stethoscope over the left sternal border 2. Placing the bell of the stethoscope over the right sternal border 3. Placing the diaphragm of the stethoscope over the left sternal border 4. Placing the diaphragm of the stethoscope over the right sternal border

3 Rationale: When assessing for a pericardial friction rub, the nurse should place the diaphragm of the stethoscope over the left sternal border. Therefore, the other options are incorrect. The nurse should also remember that a friction rub is often positional, so the nurse should listen for a rub in several positions, including supine, sitting and leaning forward, and lying on the left lateral side.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? a. Eggs b. Cereal c. Peanut butter d. Pasta

a Rationale: Complete protein contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products.

when teaching a postmenpausal client breast self-examination (BSE), what instruction would the nurse provide to the client? 1. Palpate the breasts before inspection 2. Always begin BSE on the right breast first 3. Perform BSE on the same day every month 4. Call the primary health care provider if both breasts are not the same size

3 Rationale: From 5 to 10 days after the first day of menses is the best time for a breast self-examination (BSE) in a postmenopausal client. After menopause, BSE needs to continue once a month and should be done on the same day of the month for ease in remembering to do so. As with nursing assessments, inspection is the first step in BSE. BSE may begin in either breast but is usually performed on the left breast first. Breasts of unequal size are common; changes in size or contour are findings that should be reported to the primary health care provider.

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? a. Frequent bowel sounds with flatus b. Absent bowel sounds with distention c. Hyperactive bowel sounds with diarrhea d. Normal bowel sounds with increased peristalsis

b Rationale: Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended, and there is no flatus or stool.

A nurse is assessing the client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? a. Palpation of both carotid arteries simultaneously b. Auscultation of the arteries for bruits with the bell of the stethoscope c. Palpation of the arteries for murmurs bilaterally d. Auscultation of the arteries for thrills with the diaphragm of the stethoscope

b Rationale: The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds, such as those from turbulence in blood vessels.

A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds? a. Absent b. Vesicular c. Bronchial d. Bronchovesicular

c Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi. bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client?

1,560 mL Rationale: oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve of X. 1 oz/30 mL = 4 oz/X mL X = 120 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. pints to mL: Step 1: what is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 pint/ 480 mL = 0.5 pint/X mL X= 240 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 pint = 480 mL, then 1/2 pint = 240 mL For the total intake, calculate 150 mL x 8 hr = 1,200 mL + 120 mL + 240 mL = 1,560 mL

The nurse is performing an abdominal assessment on a client. Which finding should the nurse report to the HCP? 1. Absence of a bruit 2. Concave, midline umbilicus 3. Pulsation between the umbilicus and pubis 4. Bowel sound frequency of 15 sounds per minute

3 Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the primary HCP. Bruits are not normally present. The umbilicus should be in the midline, with a concave appearance. Bowel sounds vary, according to the timing of the last meal, and usually range in frequency from 5 to 35 per minute.

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? a. Osteoporosis b. Scoliosis c. Kyphosis d. Lordosis

a Rationale: A loss of height is often an early indication of osteoporosis. This occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse. Scoliosis does not precipitate a decrease in the height of the client; it is an abnormal lateral curve of the spine. Kyphosis does not precipitate a crease in the height of a client; it is an exaggerated posterior curvature of the thoracic spine (i.e. hunchback). Lordosis does not participate a decrease in the height of a client; it is an exaggerated lumbar curvature (i.e. swayback).

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? a. Auscultation b. Light palpation c. Percussion d. Deep palpation

a Rationale: According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results.

A nurse is assessing a client who has fluid-volume excess. Which of the following should the nurse expect? a. Crackles in the lung fields b. Flat neck veins c. Postural hypotension d. Dark yellow urine

a Rationale: Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain.

A nurse is performing an assessment of a peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? a. Below the medial malleolus b. In the popliteal fossa c. In the antecubital space d. On the dorsum of the foot

a Rationale: The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle.

A nurse is implementing a cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? a. Apply a cold pack to the edematous area b. Check capillary refill before applying an ice pack to the affected area c. Half-fill an ice pack with crushed ice d. Apply an ice pack for 60 min intervals

b Rationale: The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area.

A nurse is screening clinic is assessing a client who reports a history of heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? a. Fifth intercostal space just medial to the midclavicular line b. Second intercostal space to the left of the sternum c. Fifth intercostal space to the left of the sternum d. Second intercostal space to the right of the sternum

d Rationale: The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is preforming a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? a. Percussion b. Auscultation c. Inspection d. Palpation

d Rationale: With palpation, the nurse uses touch to help detect unusual or expected sensations including temperature, texture, masses, or moisture.

The school nurse planning to give a class on testicular self-examination (TSE) at a local high school would include which instruction to the participants? 1. Perform the self-examination every other month 2. Perform the self-examination after a cold shower 3. Expect the self-examination to be slightly painful 4. Roll the testicle between the thumb and forefinger

4 Rationale: TSE is a self-screening for testicular cancer, which predominantly affects men in their teens and twenties. The self-examination is performed once a month, as is a breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The self-examination should not be panful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? a. Sodium b. Calcium c. Potassium d. Magnesium

a Rationale: Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. Calcium supports bone and tooth formation; it does not affect extracellular fluid volume. Potassium affects storage of glycogen, cardiac conduction, and smooth muscle contraction; it does not affect extracellular fluid volume. Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles; it does not affect extracellular fluid volume.

A nurse is performing an otoscopic examination of the client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? a. Obtain an audiology referral b. Document this as an expected finding c. Irrigate the ear with warm water d. Document mild inflammation

b Rationale: The light of the otoscope reflects off the tympanic membrane, which is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse documenting? a. Autonomy b. Fidelity c. Nonmaleficence d. Justice

b Rationale: The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made. The ethical principle of autonomy involves ensuring the client has the right to make personal decisions. The ethical principle of nonmaleficence involves doing no harm. The ethical principle of justice involves treating everyone fairly.

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? a. Retinopathy b. Glaucoma c. Cataracts d. Macular degeneration

b Rationale: The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? a. Exhale slowly to reach the goal volume b. Hold the breath for 5 sec after goal volume is reached c. Continue to breathe deeply between each cycle d. Limit the repeat pattern of breathing to 5 breaths

b Rationale: The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximum inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis (collapsed lung) and pneumonia.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? a. Warm, dry skin b. Increased urinary output c. Tachycardia d. Bradycardia

c Rationale: Due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate.

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? a. Peripheral pulses equal bilaterally at a rate of 60/min b. Radial, brachial, and pedal pulses bilaterally weak c. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities d. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

c Rationale: The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulses evaluation should include the strength of pulsations as well as their quality and symmetry in all 4 extremities.

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? a. "Tilt your head slightly forward" b. "Keep your head straight and look ahead of you" c. "Tilt your head back and swallow" d. "Turn your head to the side against my hand"

c Rationale: To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland.

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? a. Instill proparacaine hydrochloride eye drops b. Perform ocular irrigation of the right eye c. Place the client in a supine position with the head turned toward the affected side d. Ask the client about first aid performed at the scene

d Rationale: Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? a. Trauma b. Severe Infection c. Iron-deficiency anemia d. Chronic hypoxemia

d Rationale: Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as with COPD. It is a change in the angle between the nail and nail base, often with the enlargement of the fingertips.

As part of the cardiac assessment, to palpate the apical pulse, the nurse places the fingertips at which location? 1. At the left midclavicular line at the fifth intercostal space 2. At the left midclavicular line at the third intercostal space 3. To the right of the left midclavicular line at the fifth intercostal space 4. To the right of the left midclavicular line at the third intercostal space

1 Rationale: The point of maximal impulse (PMI), where the apical pulse is palpated, is normally located in the fourth or fifth intercostal space, at the left midclavicular line, Options 2, 3, and 4 are not descriptions of the location for palpation of the apical pulse.

After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client? 1. Waves of loud gurgles auscultated in all four quadrants 2. Soft gurgling or clicking sounds auscultated in all four quadrants 3. Low-pitched swishing sounds auscultated in one or two quadrants 4. Very high-pitched loud rushes auscultated, especially in one or two quadrants

2 Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as intestinal obstruction.

A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture? 1. "Is the pain a dull ache?" 2. "Is the pain a sharp and continuous?" 3. "Does the discomfort feel like a cramp?" 4. "Does the pain feel like the muscle was stretched?"

2 Rationale: Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Muscle injury is often described as an aching or cramping pain, or soreness. Strains result from trauma to a muscle body or an attachment of a tendon from overstretching or overextension.

The nurse is assessing a 39-year old Caucasian clients with a blood pressure (BP) of 152/92 mmHg at rest, a total cholesterol level of 180 mg/dL, and a fasting blood glucose level of 90 mg/dL. On which risk factor for coronary artery disease would the nurse place priority? 1. Age 2. Hypertension 3. Hyperlipidemia 4. Glucose intolerance

2 Rationale: Hypertension, cigarette smoking, and hyperlipidemia are major risk modifiable factors for coronary artery disease. Glucose intolerance, obesity, and response to stress are also contributing factors. An are of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 180 mg/dL and a blood glucose level of 90 mg/dL are within the normal range. The nurse places priority on major risk factors that need modification.

The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve, which action would the nurse ask the client to perform? 1. Extend the arms 2. Extend the tongue 3. Turn the head toward the nurse's arm 4. Focus the eyes on an object held by the nurse

2 Rationale: Impairment of the cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to extend the tongue. Extending the arms, turning the head toward the nurse's arm, and focusing the eyes on an object do not test the function of cranial nerve XII.

The RN s observing a new nurse auscultate the breath sounds on a client with pneumonia. Which action by the new nurse would lead the registered nurse to determine that there is a need for further teaching? 1. Asks the client to sit up straight 2. Uses the bell of the stethoscope 3. Places the stethoscope directly on the client's skin 4. Encourages the client to breathe slowly and deeply through the mouth

2 Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.

The nurse provides information to a client about performing a breast self-examination (BSE). The nurse determines that the client needs further teaching if the client makes which statements? Select all that apply. 1. "The BSE must be done monthly." 2. "Lumps in my armpit area are normal." 3. "I can palpate my breasts with soapy water while showering." 4. "I should perform the examination on the day that I start my period." 5. "When I squeeze my nipples, I should expect to note some discharge." 6. "I should stand before a mirror and inspect each breast for anything unusual."

2, 4, 5 Rationale: Any lumps (including lumps in the armpit) and nipple discharge are abnormal and must be reported to the primary health care provider immediately. The examination is performed 2 or 3 days after menstruation ends, when the breasts are least likely to be tender and swollen. The client is taught that BSE should be done once a month so that the client becomes familiar with the usual feel and appearance of the breasts. The client is taught to palpate each breast and axillary area; this part of the examination can be performed in the shower using soap, which allows the fingers to glide easily over the skin. The client is taught to also stand before a mirror to inspect each breast for anything unusual.

Which procedure would the nurse implement when performing a voice test to assess hearing on clients attending a community health screening? 1. Face the client and whisper a statement while the client blocks both ears 2. Have the client turn away from the nurse, whisper a statement, and ask the client to clearly repeat it. 3. Speak to the client while standing 4 feet away, and determine whether the client can hear at this distance 4. Quietly whisper a statement from 1 to 2 feet away, and ask the client, who has blocked one ear, to repeat it

4 Rationale: The nurse should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Options 1, 2, and 3 are incorrect procedures.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? a. Cranial nerve XII b. Cranial nerve X c. Cranial nerve VIII d. Cranial nerve V

a Rationale: The nurse is checking the function of the cranial nerve XII (hypoglossal), which innervates the tongue, by observing a range of tongue movements. The nurse checks the functioning of cranial nerve X (vagus) by asking the client to vocalize. The nurse checks the functioning of cranial nerve VIII (vestibulocochlear) through using the Rinne and Weber tests and asking the client if he can hear a whisper. The nurse checks the functioning of cranial nerve V (trigeminal) by asking the client to clench his teeth and palpating the masseter for contraction.

The nurse is preparing to auscultate bowel sounds. Which actions suggest appropriate assessment techniques and interventions? Select all that apply. 1. Divide the abdomen into four quadrants at the umbilicus 2. Do not feed the client if no sounds are audible in 5 minutes 3. Listen in each quadrant for gurgling sounds, indicating movement 4. If no sounds are audible in 2 minutes, notify the primary health care provider 5. If 20 sounds are noted within 1 minute, notify the primary health care provider 6. Hold all food until increased peristalsis occurs if bowel sounds are noted to be 15 per minute

1, 2, 3 Rationale: Dividing the abdomen into four quadrants allows listening to each section of the colon. Listening in each quadrant for gurgling sounds indicates peristalsis, which may be missed if not listened for separately. It is necessary to auscultate for 5 minutes before before determining that sounds are absent. Not hearing audible peristalsis within 5 minutes may indicate a paralytic ileus. The client is not placed on nothing-by-mouth (NPO) status unless an ileus is suspected. If an ileus is suspected, the primary health care provider is notified.

The nurse teaches a premenopause client about breast self-examination (BSE). Which information would the nurse include in her instructions? Select all that apply. 1. Inspection is part of the BSE procedure 2. Perform BSE the same way each time you do this procedure 3. Mammography should be performed prior to performing BSE 4. The best time to perform BSE is 5 to 7 days following the end of menstruation 5. Use the palm of your hand to palpate for any unusual masses in the breast tissue

1, 2, 4 Rationale: Standing before a mirror inspecting the breasts for puckering, dimpling, or changes in the contour of the breasts is an important part of breast self-examination (BSE). The procedure should be performed in the same manner each month so that there is familiarity to compare any new changes. Changes in breast size reach a minimum at 5 to 7 days after the cessation of menstruation. Mammography, a test for breast cancer, is not a component of the BSE. Fingertips, not the palmar surface of your hand, should be used to palpate breast tissue.

The nurse performing a skin assessment on a client observes a skin lesion. The nurse would notify the primary health care provider about which findings? Select all that apply. 1. Variegated color 2. Irregular borders 3. Uniform color of brown 4. Measures 2 to 3 mm in size 5. Bleeds easily with minimum pressure

1, 2, 5 Rationale: Suspicious moles have multiple colors, have irregular borders, and might tend to bleed easily. These findings should be reported to a primary health care provider as soon as possible. Moles that are very small (less than 6mm) and uniform in color are classified as benign and usually require only routine follow-up.

The nurse is working at an osteoporosis screening clinic and is interviewing and performing health assessments on women. Which clients are at greatest risk for developing osteoporosis? 1. An older adult woman 2. A large-boned, dark-skinned woman 3. A client who started menopause early 4. A client with a family history of the disease 5. A client who has a physically active lifestyle 6. A client with an inadequate intake of calcium and vitamin D

1, 3, 4, 6 Rationale: Osteoporosis is a disorder by abnormal loss of bone density and deterioration of bone tissue, with an increased fracture risk. Asian, white, small-boned, and fair-skinned women are at greatest risk for osteoporosis. Other risk factors include early menopause, a family history of the disease, and a sedentary lifestyle. Inadequate intake of calcium and vitamin D is a major risk factor because it results in abnormal loss of bone density and deterioration of bone tissue. Women who smoke, drink alcohol, or take corticosteroids or anticonvulsants, as well as those who consume excessive amounts of caffeine, also have increased risk for osteoporosis.

A school nurse is performing screening examinations for scoliosis. Which signs of scoliosis should the nurse assess for? Select all that apply 1. Chest asymmetry 2. Equal waist angles 3. Unequal rib heights 4. Equal rib prominences 5. Equal shoulder heights 6. Lateral deviation and rotation of each vertebra

1, 3, 6 Rationale: Scoliosis is a lateral curvature of the spine. The signs include nonpainful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences and chest asymmetry, and unequal rib heights.

The nurse performing a physical assessment on a client gathers both subjective and objective data. Which findings are considered objective data? Select all that apply. 1. Peripheral edema 2. Constipation lasting 3 days 3. Pain scored at 6 out of a possible 10 4. Apical pulse rate of 78 beats per minute 5. Respiratory rate of 18 breaths per minute

1, 4, 5 Rationale: The purpose of a physical assessment is to collect both subjective and objective data. Subjective data, collected during the health history, are what the client says about self. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. A client who has heart failure ad is receiving 100% oxygen via partial rebreather mask b. A client who has emphysema and is receiving oxygen at 3 L/min via transtracheal oxygen cannula c. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar d. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula

a Rationale: The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? a. Vesicular b. Bronchial c. Rhonchi d. Bronchovesicular

a Rationale: The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched.

A nurse is teaching a client how to perform range of motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? a. "With your palm facing down, move your wrist sideways toward your thumb." b. "Move your palm toward the inner part of your forearm." c. "With your palm facing down, move your wrist sideways toward your little finger." d. "Bring the back of your hand as far back toward the wrist as you can."

a Rationale: This motion describes adducting the wrist. The client should be able to move her wrist 30 degrees to 50 degrees with this motion.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? a. Repeat each joint motion 5 times during each session b. Move the joint to the point of considerable resistance c. Sit approximately 2 ft from the side of the bed closest to the joint being exercised d. Exercise the smaller joints first

a Rationale: To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times.