Midterm Practice test

A. Contractures of the extremities D. Crackles in the lungs E. Pressure ulcers

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? Select all that apply A. Contractures of the extremities B. Polyuria C. Diarrhea D. Crackles in the lungs E. Pressure ulcers

B. Prior to percussing the abdomen

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

A. Ask the client to read a Snellen Chart

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II? A. Ask the client to read a Snellen Chart B. Listen to the client's speech C. Ask the client to identify scented aromas D. Ask the client to clench his teeth

A. At the end

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen

C. Conjuctivae

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? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjuctivae D. Dorsal surface of the foot

C. Do you have difficulty staying awake when you are driving?"

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client? A. "Are there any specific factors that you think are affecting your ability to sleep?" B. Can you describe your bedtime routine to me?" C. Do you have difficulty staying awake when you are driving?" D. When did you begin to have trouble sleeping?"

C. Performs active range-of-motion (ROM) exercises of all extremities

A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? A. Needs assistance raising her legs to put on socks B. Demonstrates mild dyspnea when eating breakfast C. Performs active range-of-motion (ROM) exercises of all extremities D. Develops fatigue when assisting with morning hygiene care

A. The client takes alprazolam

A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls? A. The client takes alprazolam B. The client has a nonslip bath mat in his shower C. The client uses a raised toilet seat D. The client wears fitted slippers

D. Water heater temperature 54.4 C (130F) E. Throw rugs

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? Select all that apply A. Bathtub with rails B. Electric cords behind the furniture C. Raised toilet seats D. Water heater temperature 54.4 C (130F) E. Throw rugs

B. Document the client's verbatim statements

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first? A. Ask the client for permission to take photographs B. Document the client's verbatim statements C. Provide community sexual assault support contacts D. Determine any physical signs of injury

A. Mental status examination (MSE)

A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment? A. Mental status examination (MSE) B. Brief Patient Health Questionnaire ( Brief PHQ) C. Abnormal Involuntary Movement Scale (AIMS) D. Scale for Assessment of Negative Symptoms (SANS)

C. A client's blood pressure changes from 112/60 mmHg to 90/54 mm Hg when standing

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately? A. A client who is 1 day postoperative and has temperature of 37.5 C ( 99.5F) B. A client who has a burn injury to an estimated 5% his leg and is crying C. A client's blood pressure changes from 112/60 mmHg to 90/54 mm Hg when standing D. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation

C. Leave a nightlight on in the client's room

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening B. Obtain a bedside commode for the client's use C. Leave a nightlight on in the client's room D. Put the side rails up and tell the client to call the nurse before voiding

D. Ecchymosis

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? A. Symmetrical convex sphere shape B. Concave umbilicus C. Bilateral bowel sounds in lower quadrants D. Ecchymosis

C. Document the client's allergies in the electronic medical record

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? A. Teach the client about his diagnosis B. Provide a schedule of visiting hours to the client's family C. Document the client's allergies in the electronic medical record D. Develop a plan of care for the client

C. "How do you handle stress?"

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? A. "Does your skin condition keep you awake at night?" B. "Have you had any changes in your diet?" C. "How do you handle stress?" D. "How does your skin condition make you feel?"

D. Reaches over the bed to straighten the fitted sheet

A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene? A. Raises the bed to waist level B. Rolls the client to one side of the bed C. Lowers the side rail on the side of the bed closest to the AP D. Reaches over the bed to straighten the fitted sheet

A. Decreased muscle mass

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include? A. Decreased muscle mass B. Thickened vertebral disks C. Reduced chest width D. increased force of isometric contraction

B. Apex of the heart

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? A. Carotid artery B. Apex of the heart C. Brachial artery D. Radial artery

B. The client's current weight-bearing status

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? A. The client's ability to communicate B. The client's current weight-bearing status C. The client's heigh D. The type of equipment used in previous transfers

A. "It is a good idea to use the handrails in the bathroom."

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? A. "It is a good idea to use the handrails in the bathroom." B. " I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "I should get a longer cord for my telephone."

A. Check for personal items when changing the bed linens C. Keep the bath water temperature between 43.3 C (110F) and 46.1 C (115 F) D. Shave the client's hair in the direction of the hair growth

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? Select all that apply. A. Check for personal items when changing the bed linens B. Place a clean gown on the strongest arm first C. Keep the bath water temperature between 43.3 C (110F) and 46.1 C (115 F) D. Shave the client's hair in the direction of the hair growth E. Wash the client's extremities from proximal to distal

A. Clean under the nail with an orange stick

A nurse is providing nail care for a client. Which of the following actions should the nurse take? A. Clean under the nail with an orange stick B. File the nails in a rounded shape C. Push the cuticles back with a metal nail file D. Trim the nails at the lateral corners

C. Turn the client on his side before starting oral care

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Use a stiff toothbrush to clean the client's teeth B. Use the thumb and index finger to keep the client's mouth open C. Turn the client on his side before starting oral care D. Apply petroleum jelly to the client's lips after oral care

D. "I will place a bath seat in my shower to use when I bath."

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will keep my walker at the end of my bed." B. "I will keep the fluorescent ceiling light on in my room at night." C. "I will place an area rug at the entry of my bathroom." D. "I will place a bath seat in my shower to use when I bath."

A. Keep the box close to his body as he lifts

A nurse needs to life a box in a supply room. Which of the following actions should the nurse take to prevent an injury due to lifting? A. Keep the box close to his body as he lifts B. Stand with his feet close together when lifting C. Bend at the waist to pick up the box D. Twist when placing the box to his side

A. An older adult client who is confused and has urinary frequency

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for fall? A. An older adult client who is confused and has urinary frequency B. A client with diabetes mellitus who has a leg ulcer C. A client who is 1 day postoperative and has a nursing assistant helping him out of bed D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days

D. Dysphagia

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. Pruritus C. Urinary hesitancy D. Dysphagia