Passpoint: Basic Physical Assessment

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include? "At first, the stoma may bleed slightly when touched." "A burning sensation under the stoma faceplate is normal." "The stoma should appear dark and have a bluish hue." "The stoma should remain swollen distal to the abdomen."

"At first, the stoma may bleed slightly when touched." For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? "The pulse can't be checked accurately if the arteries are palpated at the same time." "Checking both carotid arteries at the same time may impair cerebral circulation." "Checking both carotid arteries at the same time may cause transient hypertension." "Checking both carotid arteries at the same time may cause severe tachycardia."

"Checking both carotid arteries at the same time may impair cerebral circulation." The carotid arteries must be palpated one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia (not tachycardia) could lead to cardiac arrest. Palpating both carotid arteries at the same time doesn't cause hypertension.

The nurse-manager asks a newly hired LPN if the facility's rules of ethical conduct are understood. Which statement by the LPN indicates the need for further education? "I'll support the Patient Care Partnership." "I make sure that I do everything in my client's best interest." "I don't discuss advance directives unless the client initiates the conversation." "I maintain client confidentiality at all times."

"I don't discuss advance directives unless the client initiates the conversation." The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the nurse must address this question regardless of whether the client initiates a conversation about it. Nurses need to always act in the best interest of their clients, maintain confidentiality, and support the Patient Care Partnership.

The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond? "The client's body is supine." "The client's body is facing backward." "The client's palms are turned forward." "The client's arms are elevated at shoulder level."

"The client's palms are turned forward." In the anatomic position, the body is erect, facing forward with arms at the sides and palms turned forward.

The newly-hired nurse is monitoring a client for adverse reactions during barbiturate therapy. The nurse preceptor asks what is the major disadvantage of barbiturate use. What is the best response by the newly-hired nurse? "There is poor absorption of the barbiturate." "There is a potential for hepatotoxicity with barbiturates." "There is a potential for drug dependence with barbiturates." "Barbiturates have a prolonged half-life."

"There is a potential for drug dependence with barbiturates." Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, although existing hepatic damage does require cautious use of the drug because barbiturates are metabolized in the liver.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation? "They are progressively deeper breaths followed by shallower breaths with apneic periods." "They are rapid, deep breaths with abrupt pauses between each breath." "Cheyne-Stokes shallow breaths with an increased respiratory rate." "Cheyne-Stokes are rapid, deep breaths and irregular breathing without pauses."

"They are progressively deeper breaths followed by shallower breaths with apneic periods." Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

A client reports abdominal pain. Which question asked by the nurse would provide the most information about the client's pain? "Is the pain radiating anywhere else?" "Does the pain come and go?" "Does resting make the pain better?" "What does the pain feel like?"

"What does the pain feel like?" An open-ended question (one that can't be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are close-ended questions.

An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection? Shortening it Talking in a loud voice Addressing the client by his first name Allowing extra time for this task

Allowing extra time for this task When collecting data on an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, should address the client respectfully rather than by his or her first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

A nurse is reviewing a client's chart. Which documentation does the nurse expect to find to indicate that the client's reaction is a normal response to a corneal sensitivity test? Blinking Pupil dilation Pupil contraction Seeing a flash of light

Blinking The normal response to a corneal sensitivity test is blinking. Sudden onset of seeing spots or flashing lights may indicate retinal detachment. Pupil dilation occurs when the eye is exposed to darkness. Pupil contraction normally occurs when the pupil is exposed to direct light.

A licensed practical nurse (LPN) who typically works on a medical-surgical unit is being cross-trained to work with postpartum clients. The nurse-manager is busy with a client who is giving birth and assigns the LPN to stock client rooms. Entering a client's room, the LPN notices that the client looks pale and shaky. Which action should the LPN take? Quickly finish stocking the room and tell the client to press the call button for a regular staff nurse. Stop stocking the room, and inform the nurse-manager that the client needs to be evaluated by a registered nurse. Find another LPN to help evaluate the client and confirm the observations. Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager.

Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager. Licensed professionals are always held accountable for practicing according to the level of education they have attained. Therefore, even though the LPN has been assigned to do work usually done by a nursing assistant, the LPN is held accountable within the standards of practice for an LPN. It is within the scope of practice for an LPN to collect vital signs data, complete a cursory examination of the client's fundus and flow, and report findings to the nurse-manager. The client should not be left alone until the LPN establishes through data collection that doing so is safe for the client. If the client is unstable, the LPN should stay with the client and call for help.

A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform? Administer naloxone. Check the glucose level. Perform an electrocardiogram. Perform an electroencephalogram.

Check the glucose level. Blood glucose level should be immediately measured when a client is unresponsive for no apparent reason or if hypoglycemia is suspected. This client is NPO and at risk for hypoglycemia. When blood glucose levels fall below 40 to 50 mg/dL, cerebral function declines rapidly. An ECG or EEG may be performed but would not be the priority in this situation. There is no indication that the client has received a narcotic, so the administration of a narcotic antagonist would be unnecessary.

A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client? Polyuria, polydipsia, polyphagia, and weight loss Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin Polyuria, polydipsia, hypotension, and hypernatremia Kussmaul respirations, dry skin, hypotension, and bradycardia

Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin Signs and symptoms of hypoglycemia (glucose level below 70 mg/dL) include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, decreased LOC, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs and symptoms of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

A nurse is performing a head-to-toe assessment. Which part of the hand should the nurse use to evaluate this client's body for warmth? Ulnar surface Finger pads Dorsal surface Fingertips

Dorsal surface To feel for warmth, the nurse should use the dorsal surface, or back, of the hand. The fingertips are best for distinguishing texture and shape; the finger pads, for assessing hair texture, grasping tissues, and feeling lymph node enlargement; and the ulnar surface, for feeling thrills and fremitus.

A nurse is evaluating a client for the risk of falls. What information should the nurse collect? Family's psychosocial history Facility's restraint policy Client's dietary preferences Gait and balance information

Gait and balance information Evaluating the client's gait and balance helps determine the risk of falls. The facility's policy on restraints isn't relevant to a risk evaluation for falls. Evaluating the family's psychosocial history and the client's dietary preferences are not as important as gait and balance in relation to the risk of falls.

All of the following components may be part of a client's medical record. When reviewing the client's chart, which will the nurse identify as the major source of subjective data about the client's health status? Laboratory test results Radiologic findings Health history Physical findings

Health history Only the health history provides subjective data. Physical findings, laboratory test results, and radiologic findings are examples of objective data.

A nurse is discussing skin turgor evaluation of an elderly client with her peers. While doing so, the nurse should include which information with her colleagues? Inelastic skin turgor is a normal part of aging. Dehydration causes the skin to appear edematous and spongy. Normal skin turgor is moist and boggy. Overhydration causes the skin to tent.

Inelastic skin turgor is a normal part of aging. Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

The nurse is assisting with the care of a neonate born to a mother with type 1 diabetes. When gathering data on the neonate, the nurse would suspect that the neonate is experiencing hypoglycemia based on which finding? Peripheral acrocyanosis Lethargy Bradycardia Jaundice

Lethargy Lethargy in a neonate may be caused by hypoglycemia due to of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in a neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice is not a sign of hypoglycemia.

A 76-year-old client with no debilitating conditions belongs to which geriatric population? Frail elderly Young-old Old-old Middle-old

Middle-old A 76-year-old client with no debilitating conditions belongs to the middle-old geriatric population. The young-old geriatric population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is another group, the frail elderly, which includes all individuals older than age 65 who have one or more debilitating conditions.

The nurse mentor is observing a newly hired nurse while she performs a head-to-toe assessment. The mentor knows the newly hired nurse is effective in evaluating a client's posterior tibial pulse when she palpates which area? Midway between the superior iliac spine and symphysis pubis On the inner aspect of the ankle, below the medial malleolus Medially in the antecubital space Along the top of the foot, over the instep

On the inner aspect of the ankle, below the medial malleolus To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.

A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. The LPN is deciding which tasks to perform and which to delegate to an unlicensed assistive personnel (UAP). Which task must the LPN perform? Assisting the clients with their meal trays Performing dressing changes Assisting clients with personal hygiene needs Obtaining vital signs

Performing dressing changes UAP can't perform dressing changes; this measure must be performed by a licensed nurse. UAP, according to their job description, can assist with meals, obtain vital signs, and assist with hygiene measures.

The health care provider orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions? Place an isolation cart with gloves and gowns outside the room. Require anyone having direct contact to wear a respirator mask. Pull the curtain to separate the client from the client's roommate. Place a box of surgical masks outside the client's room.

Place an isolation cart with gloves and gowns outside the room. Effective contact precautions require the use of gloves and gowns by anyone who comes in contact with the client. Placing an isolation cart outside the client's room makes these supplies readily available to health care workers who must enter the client's room. Clients who require contact precautions should be placed in a private room when possible. Surgical masks are unnecessary for clients on contact precautions and are used for clients in droplet precautions. Respirator masks are required when clients are in airborne precautions.

A client requests something to treat his constipation. The client's medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse (RN) before administering the laxative? Presence of blood in the client's stool Incontinence of liquid stool Complaints of abdominal fullness Abdominal distention

Presence of blood in the client's stool Blood in the stool isn't a common sign of constipation and could indicate a more serious condition. Complaints of abdominal fullness, liquid stool, and abdominal distension are all associated with constipation and don't require reporting to the RN.

A nurse is using the Glasgow Coma Scale (GCS) to help determine a client's level of consciousness (LOC). Based on a calculated score on the GCS of 10, what conclusion does the nurse draw? The client is in a deep coma with a poor prognosis. The client has scored the highest possible score and has no impairment. The client has a decreased LOC but is not in a deep coma. The client is alert and oriented but minimally impaired.

The client has a decreased LOC but is not in a deep coma. On the Glasgow Coma Scale, a score of 8 or less indicates a coma and a poor prognosis. The highest possible score is 15. A score of 13 occurs in a client who is alert and oriented. A score of 10 indicates a decreased LOC but not a deep coma.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. On a return visit to the health care provider, the nurse observes the gait. Which observation indicates the need to reinforce client education about walker use? The client backs up to the chair until his legs touch the chair, and then sits down. The client moves his hands to the chair armrests before lowering himself into the chair. The client moves his weak leg forward with the walker. The client's arms are fully extended when using the walker.

The client's arms are fully extended when using the walker. When using a walker, the client's arms should be slightly bent at the elbow, allowing maximum support from the arms while ambulating. The weak leg is always moved forward first with the walker to provide the maximum support. When sitting, the client should always back up to the chair and feel the chair with his legs before sitting. The client should use the armrests of the chair for support because the armrests are more stable than the walker.

A nurse is collecting data on an older adult client. Which finding should the nurse anticipate as part of the normal degenerative changes associated with aging? fine tremors cloudy vision incontinence diminished reflexes

diminished reflexes Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology and shouldn't be considered normal results of aging.

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary? To ensure that the child can't consciously raise or lower the heart rate To compensate for the effects of activity on the heart rate To eliminate interference from the jerky movements of chorea To obtain a heart rate that isn't affected by medication

To compensate for the effects of activity on the heart rate Tachycardia may be a sign of heart failure. Mild tachycardia is more easily detected during sleep than while the client is awake, when activity can cause an increase in heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin, exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. However, it doesn't affect pulse because the child would be sitting quietly and not involved in purposeful movement. A 10-year-old child is unlikely to be able to consciously raise or lower his heart rate.

The nurse is gathering vital signs on a client. Blood pressure reading is 180/100 mm Hg by electronic blood pressure cuff. Place in order the steps that should be taken. Wait 5 minutes, Perform a manual blood pressure, Notify the RN, Notify the health care provider Notify the RN, Wait 5 minutes, Notify the health care provider, Perform a manual blood pressure Notify the RN, Wait 5 minutes, Perform a manual blood pressure, Notify the health care provider Notify the health care provider, Notify the RN, Wait 5 minutes, Perform a manual blood pressure

Wait 5 minutes. Perform a manual blood pressure. Notify the RN. Notify the health care provider.

When assessing pain in a 5-year-old verbal child, which appropriate pain scale would the nurse use? Wong-Baker Faces Pain Scale FLACC Pain Scale Pain Intensity Scale Pain Distress Scale

Wong-Baker Faces Pain Scale Wong-Baker Faces Pain Scale is used for verbal children between 3 and 7 years of age. Pain Intensity Scale and Pain Distress Scale are usually used for children older than 7 years of age and for adults. The FLACC Pain Scale is usually used for preverbal children younger than 3 years of age; it may also be used for severely intellectually impaired clients.

The nurse has just received the shift report. Which client should the nurse assess first? a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84% an 88-year-old client admitted with mental status changes whose vital signs are stable a 35-year-old client who had an abdominal hysterectomy 2 days ago and has stable vital signs a 76-year-old client admitted with chest pain whose last blood pressure was 136/92 mm Hg

a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84% The client with COPD and low oxygen saturation levels would be the priority when planning care. The ABCs of assessment (airway, breathing, circulation) outline the priorities for care. The postsurgical client and the two observation clients are stable and in no apparent distress. These clients need careful assessment and frequent monitoring but aren't the priority for the nurse.

A nurse is collecting data on a client with possible osteoarthritis. What factor places this client at the greatest risk for osteoarthritis? trauma age genetics obesity

age Age is the most significant risk factor for osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events, such as trauma.

The nurse is caring for a client who states an increase in dyspnea. Which intervention would the nurse perform first? call the HCP assess vitals prepare a breathing treatment apply an oxygenated mask

assess vitals Assessment is the first step in the nursing process/data collection. Assessing the pulse oximeter reading provides valuable information on the client's condition. Once the information is known, obtaining a breathing treatment or applying an oxygenated face mask, especially for a pulse oximeter reading under 90%, is appropriate. Health care provider notification would also be necessary because oxygen is a medication requiring an order.

A nurse is caring for a client with a fractured left femur. Which finding would require the nurse to contact the health care provider immediately? swelling and bruises on the left leg dyspnea and increasing restlessness nausea, vomiting, and loss of appetite left leg cramping and reports of fatigue

dyspnea and increasing restlessness The nurse should monitor a client with a fractured femur for a fat embolus, which can occur with fractures of the long bones and pelvis. Clinical manifestations include dyspnea, tachycardia, chest pain, tachypnea, cyanosis, apprehension, restlessness, confusion, petechiae, and decreased PaO2. Dyspnea and increasing restlessness indicate an oxygenation issue. Nausea, vomiting, loss of appetite, cramping, and fatigue are not associated with fat emboli. Swelling, bruising, or pain may be expected with a fractured extremity. All these findings require follow-up but the priority is symptoms of a fat embolus, which indicates an oxygenation issue.

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care? lacerations head injuries bleeding and bruising controlled bleeding

head injuries Clients with head injuries are the highest priority because of potential brain damage and spinal cord injury. The other options identified are not life threatening. All are important, but based on ABCs, head injury is first.

A client reports slipping on a throw rug while going to the bathroom at night. Which data should be gathered for prevention of further falls? home safety client confusion injury to the client's head client has a urinary tract infection (UTI)

home safety A safety assessment of the home can determine if changes need to be made to ensure the client doesn't fall again. The nurse might or might not determine if the client has experienced a head injury or confusion by asking how the injury occurred. Going to the bathroom at night isn't necessarily a sign of a UTI.

What retractions are seen here?

intercostal retractions

A client underwent a bowel resection and has been using an incentive spirometer postoperatively. Which finding indicates to the nurse that the client's use of incentive spirometry is effective? respiratory rate 20 breaths per minute and shallow partial pressure of oxygen (PaO2) 78 mm Hg partial pressure of carbon dioxide (PaCO2) 48 mm Hg oxygen saturation level 96% on room air

oxygen saturation level 96% on room air A pulse oximeter measures oxygen saturation, not respiratory rate, PaCO2, or PaO2. Oxygen saturation is an indicator of the effectiveness of incentive spirometry.

A primipara client at 32 weeks' gestation comes to the hospital reporting vaginal bleeding. She has soaked one peri-pad and has no pain or cramps. Based on this data, the nurse would most likely suspect which condition? vasa previa incompetent cervix placenta previa abruptio placentae

placenta previa Painless vaginal bleeding is the classic sign of placenta previa. Abruptio placentae is painful. Vasa previa occurs with ruptured membranes. An incompetent cervix causes pressure sensations.

The nurse is obtaining vital signs for several clients. Which client's vital signs would be the priority to report to the health care provider? postoperative client with a pulse of 110 beats/minute on awakening in the morning healthy female client undergoing elective surgery with a blood pressure of 110/68 mm Hg healthy male client who is undergoing elective surgery with a blood pressure of 120/72 mm Hg client with a pulse of 120 beats/minute after 30 minutes of aerobic exercise in physical therapy

postoperative client with a pulse of 110 beats/minute on awakening in the morning The normal range for a pulse is 60 to 100 beats/minute and, in the morning, the rate is at its lowest. Blood pressures of 120/72 mm Hg for a healthy man and 110/68 mm Hg for a healthy woman are normal. Aerobic exercise increases the heart rate over the normal range of 60 to 100 beats/minute.

When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education? reduced intelligence electrolyte imbalances slowed reaction time increased vein elasticity

slowed reaction time Slowed reaction time is a normal age-related change in older adult clients. Although the client's intelligence should remain intact, aging may slow learning speed. Electrolyte imbalances are abnormal findings in clients of any age. With age, vein elasticity usually decreases, not increases.

What retractions are seen here?

subcostal retractions

What retractions are seen here?

suprasternal retractions

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing? three to four peristaltic sounds per minute at least 15 blowing sounds per minute eight high-pitched tinkling sounds per minute 36 or more short sounds per minute

three to four peristaltic sounds per minute When a paralytic ileus occurs, bowel sounds become hypoactive or absent. Hyperactive bowel sounds (more than 35 short sounds per minute) may signify hunger, intestinal obstruction, or diarrhea. High-pitched tinkling sounds may signify a dilated bowel. A blowing sound may be a bruit from a partially obstructed abdominal aorta.

The nurse is collecting data on a client before surgery. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications? "I had an operation 2 years ago, and I don't want to have another one." "I've never had surgery before." "I haven't been able to eat anything solid for the past 2 days." "I've cut my smoking down from two packs to one pack per day."

"I've cut my smoking down from two packs to one pack per day." Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery. Lack of solid foods for 2 days before surgery, no history of previous surgery, and anxiety about surgery wouldn't increase the risk of postoperative complications.

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response? "The mother will have less trouble holding a quiet, upright infant." "Lying down can cause the fontanels to recede, making assessment more difficult." "The infant can breathe more easily when sitting up." "Lying down and crying can cause the fontanels to bulge."

"Lying down and crying can cause the fontanels to bulge." Lying down and crying can cause the fontanels to bulge, giving the nurse inaccurate data. The nurse should sit the child upright and try to keep him or her calm and quiet. The fontanels should look almost flush with the scalp and surface, and slight pulsation should be visible. The fontanels should feel soft and either flat or slightly indented.

An elderly client is scheduled for discharge from the hospital. Which statement by the client indicates that further teaching is needed? "My daughter keeps my house clean and puts things away for me." "I don't have any stairs in my home." "I just had new carpet installed in my living room." "My daughter just recently waxed my hardwood floors."

"My daughter just recently waxed my hardwood floors." Waxed floors are a safety concern because they're commonly slippery and can cause falls. Elderly individuals typically have difficulty with stairs, so it's good that the client has no stairs in his home. Having a family member who keeps the home clean and clutter-free will help reduce the risk of falls. New carpet is favored over older carpet. Carpet shouldn't be torn or loose as this could contribute to a fall; new carpet that has been professionally installed shouldn't cause problems for the client.

The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation? "S1 is loudest at the apex, and S2 is loudest at the base." "S1 and S2 sound fainter at the base." "S1 and S2 sound equally loud over the entire cardiac area." "S1 and S2 sound fainter at the apex."

"S1 is loudest at the apex, and S2 is loudest at the base." The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? "The bell detects high-pitched sounds best." "The diaphragm detects high-pitched sounds best." "The bell detects thrills best." "The diaphragm detects low-pitched sounds best."

"The diaphragm detects high-pitched sounds best." The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash? Select all that apply. "What have you been using to treat the rash?" "When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "How old are you?" "Do you smoke cigarettes or drink alcohol?" "Have you recently traveled outside the country?"

"When did the rash start?"; "Are you allergic to any medications, foods, or pollen?"; "What have you been using to treat the rash?"; "Have you recently traveled outside the country?" The nurse should first find out when the rash began; this can assist with the correct diagnosis. The nurse should also ask about allergies; rashes can occur when a person changes medications, eats new foods, or contacts pollen. It is also important to find out how the client has been treating the rash; some topical ointments or oral medications may worsen it. The nurse should ask about recent travel; exposure to foreign foods and environments can cause a rash. The client's age and smoking and drinking habits would not provide further insight into the rash or its cause.

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that further visual evaluation is needed? 6-month-old infant who fixes on an object and whose head moves and eyes follow the object 9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart 15-year-old with 20/20 vision in both eyes 4-year-old with 20/40 vision in both eyes

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart The client with a difference of vision between the eyes of two or more lines on the Snellen chart requires further visual evaluation. The other three responses are within the expected parameters for their age groups.

The nurse educator is explaining to a group of newly hired nurses how to auscultate a client's chest. What information would the nurse educator include to explain how to differentiate a pleural friction rub from other abnormal breath sounds? A rub occurs during inspiration only and clears with coughing. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. A rub occurs during inspiration only and may be heard anywhere. A rub occurs during expiration only and produces a light, popping, musical noise.

A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound. Other abnormal sounds may clear with coughing, but pleural friction rubs don't.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority? Complete the client's registration information, perform an electrocardiogram (ECG), gain I.V. access, and take vital signs. Gain IV access, give sublingual nitroglycerin and a dose of aspirin, and alert the cardiac catheterization team. Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the primary care provider.

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin. Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. Aspirin is given to suppress platelet aggregation. The nurse should administer nitroglycerin for chest pain. IV access is needed for medication administration, and an ECG is used to evaluate cardiac function. Registration information can be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial evaluation is premature.

A nurse is collecting data on an 80-year-old client. Which finding best aligns with the developmental stage of the client at this age? Admits that wisdom can be provided to others based on experience Demonstrates behaviors that indicate withdrawal from activities Voices the achievement of goals that are indicative of self-realization Verbalizes that retirement allows the time needed for self-expression

Admits that wisdom can be provided to others based on experience The 80-year-old client is at the socialization developmental stage, which allows the sharing of wisdom and courage. Individuals typically achieve self-realization during middle life (between ages 46 and 64); during this time, individuals also tend to withdraw from mental activity or overcompensate by trying impossible tasks. Retirement begins in the early later years (between ages 65 and 79).

An elderly client is admitted to the medical-surgical unit. What must the nurse recall when routinely gathering data for a client for any atypical signs or symptoms? Select all that apply. Aging can increase pain perception. Aging can decrease the awareness of body orientation. The risk of developing emphysema is highest in elderly people. Anesthesia usually causes psychotic behavior postoperatively in a geriatric client. Aging can reduce the body's ability to regulate body temperature.

Aging can reduce the body's ability to regulate body temperature; Aging can decrease the awareness of body orientation During data collection, the nurse should remember that aging can reduce the ability to regulate body temperature. This not only increases the geriatric client's susceptibility to hyperthermia and heatstroke but also decreases the ability to produce a fever in response to infection. A reduced sense of touch can decrease the awareness of body orientation, which can lead to accidents, especially falls. A geriatric client may exhibit decreased (not increased) pain perception. Many medications, such as anesthetic agents and analgesics, can cause confusion or depression (not psychotic behavior) in a geriatric client. The risk of developing emphysema is highest in smokers, regardless of age.

A nurse participating in planning care for a client who is in labor expects to monitor the client's blood pressure frequently. Why is this action important? Blood pressure decreases at the peak of each contraction. Decreased blood pressure is the first sign of preeclampsia. Decreased blood pressure is a sign of maternal pain. Alterations in cardiovascular function affect the fetus.

Alterations in cardiovascular function affect the fetus. During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.

An adolescent female arrives in the emergency department after a physical assault. The suspected attacker was also brought to the hospital for treatment of injuries. A male health care provider is assigned to examine the client. Which action would best protect the client's rights during the physical examination? Leave the door open so that other staff can observe the interaction. Keep the client's friends informed of her medical condition. Arrange for a female health care worker to be present. Place the suspected attacker in the examination room next to the client.

Arrange for a female health care worker to be present. A female health care provider should be present to observe the examination when it is performed by a male health care provider. Leaving the door open and informing the client's friends of her condition violates the client's right to privacy and confidentiality. The suspected attacker, if possible, should be placed in a room that is not near the client.

The physician states that he'll refer his client to a home health agency after discharge from the hospital. When is the most appropriate time for a referral to be initiated for a hospitalized client? After discharge The day of discharge As soon as the need is identified 2 days prior to discharge

As soon as the need is identified A referral requires time to implement and should be initiated as soon as the need for referral is identified. Doing so allows time for the referral to be processed before discharge. Waiting until the day of discharge or 2 days before discharge may not allow adequate planning. The referral should always be completed before the client is discharged.

The nurse is caring for a client who had a bronchoscopy performed 60 minutes ago. The client reports being thirsty and requests a drink of water. What is the priority intervention by the nurse? Give the client water. Assess the gag reflex. Administer metoclopramide 10 mg I.V. Withhold food or fluids for 4 hours after the procedure.

Assess the gag reflex. During a bronchoscopy, a lidocaine-based spray is administered to the client's oropharynx, which causes numbness. If the client has food or fluids while the gag reflex is absent, there is a risk for aspiration. The gag reflex should be assessed before giving the client food or fluids. The administration of metoclopramide at this time is not necessary because the client is not having any gastrointestinal upset.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes. Place the client on NPO status, and notify the health care provider immediately.

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Gathering information regarding possible causes of nausea helps identify changes and factors that relate to the changes. Modifying the schedule helps. Although administering an antiemetic may be beneficial, movement and activity immediately afterward will not be helpful, because the medication has not yet taken effect. Diet is not the issue, so the diet-related choice is not correct. Nausea and weakness are not an emergency and do not require immediate notification of the health care provider.

Which trait is the most important for ensuring that a nurse-manager is effective? Clinical abilities Communication skills Time management skills Health care experience

Communication skills Communication skills are a necessity for a successful nurse-manager. The manager must be able to communicate with the staff, clients, and family members. Clinical abilities, experience, and time management are also important to the manager's success, but without communication skills the manager won't be effective.

A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take? Instruct the client to call the home health agency when he arrives home. Contact the home health agency and provide a report of the client's condition and needs. Notify the social worker of the discharge plans. Notify the pharmacy of the client's medications.

Contact the home health agency and provide a report of the client's condition and needs. The nurse should provide a report to the home health agency to facilitate continuity of care. The nurse can provide the home health agency with information regarding the specific needs of the client. It isn't necessary for the client to contact the home health agency because hospital personnel should handle this task. Although it's important for the social worker and pharmacy to be included in discharge planning, the nurse's most important consideration is to ensure that the home health agency is aware of the client's specific needs.

The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap? Take blood pressure readings in both arms. Have the client lie down while taking his or her blood pressure. Inflate the cuff to at least 200 mm Hg. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.

Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.

The nurse monitoring a client's pulse notes that it is easily palpable at 84 beats/minute and regular. Which term would the nurse use in charting the pulse assessment? Bradycardia Tachycardia Regular Dysrhythmia

Regular The pulse is regular when it is rhythmic, easily palpable, and between the rate of 60 and 100 beats/minute. Tachycardia is a heart rate faster than 100 beats/minute. Dysrhythmia is a heart rate with either irregular rate or rhythm. Bradycardia is a heart rate slower than 60 beats/minute.

A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next? Swab the tonsillar areas from top to bottom. Swab the tonsillar areas from side to side, avoiding inflamed areas. Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth. Swab the back of the tongue, then the tonsillar areas from side to side.

Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth. The nurse should obtain the specimen by swabbing the tonsillar areas, including the inflamed and purulent sites, from side to side. The nurse should avoid touching the tongue, cheeks, and teeth with the swab to prevent contaminating the specimen.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take? Accept the drug allergy listing in the medical record because the client doesn't know what allergies the client has. Discuss only the most recent drug allergies with the client as these are the most important to know. List only drug allergies on the list that the client can remember having a serious reaction to. Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment. It is helpful for the nurse to review the documented drug allergy listing and to use this as a basis for an assessment and discussion with the client. Drugs identified as contributing to an allergic reaction must be recognized and avoided as a serious risk to the client. It is poor practice not to pursue an allergy assessment simply because a client initially reports not being sure exactly what allergies are present; the client may respond well to prompting and an engaged interview. The goal of the nurse is to reach the most complete history and assessment possible with the client. Allergies can occur at any point in treatment, so the most recent allergies do not hold increased importance.

What finding would the nurse expect to see in a client admitted for possible Cushing's syndrome? thick, coarse skin with thinning hair and nails buildup of adipose tissue in the face and trunk hypotension, tachycardia, and tachypnea weight gain in the upper and lower extremities

buildup of adipose tissue in the face and trunk In a client with Cushing's syndrome, changes in fat distribution cause adipose tissue to accumulate in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Clients with Cushing's syndrome experience hypertension caused by fluid retention. The skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate what condition? epistaxis infection cerebrospinal fluid leak presence of a foreign body

cerebrospinal fluid leak Clear, thin nasal drainage may indicate a cerebrospinal fluid leak. The nurse should immediately report this finding to the health care provider. Clear, thin nasal discharge doesn't indicate infection, epistaxis, or the presence of a foreign body.

What retractions are seen here?

clavicular retractions

A home health nurse is evaluating a client's fall risk. Which observations would concern the nurse? wearing slippers with a non-skid bottom decreased strength in lower extremities holding a cane on the uninvolved side using a bath seat when showering

decreased strength in lower extremities Physiological changes such as a decline in strength can increase a client's susceptibility to falls. Proper use of cane ambulation includes holding the cane close to the body on the uninvolved side. Footwear with non-skid bottoms and using a bath seat when showering can reduce the risk of falls.

A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client? headache, fever, and diaphoresis vertigo, weakness, and pulse changes hypotension, rapid pulse, and shortness of breath insomnia, cough with hemoptysis, and fatigue

hypotension, rapid pulse, and shortness of breath Because an MI decreases cardiac output, it causes such symptoms as hypotension, rapid pulse, and shortness of breath. The other evaluation findings are not indicative of an MI.

The nurse is preparing to gather data on a school-aged child with abdominal discomfort. Place the following assessment skills in order of when the nurse would use them. palpation, auscultation, percussion, inspection inspection, palpation, auscultation, percussion auscultation, percussion, inspection, palpation inspection, auscultation, percussion, palpation

inspection, auscultation, percussion, palpation When caring for a school-aged child with abdominal pain, the nurse must consider the child's developmental level and assess the abdomen starting with the least traumatic assessment. Inspection requires no physical contact by the nurse. The nurse evaluates the look of the abdomen, posture of the child, and whether the child demonstrates any guarding. The nurse then auscultates bowel sound patterns and percusses for tones. Lastly, the nurse palpates for pertinent information regarding any abnormal abdominal masses or specific area of pain.

The nurse is working in a public health clinic. Which disorder, displayed in the picture, requires disclosure to public health officials?

rubella (German measles) rash Picture is a rubella (German measles) rash. Rubella is a contagious viral infection known for its distinctive red rash. Because of vaccines, it is not seen often but is still classified as a communicable disease.

A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client? insomnia, cough with hemoptysis, and fatigue vertigo, weakness, and pulse changes headache, fever, and diaphoresis hypotension, rapid pulse, and shortness of breath

sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

A client is admitted to the hospital after an episode of right-sided weakness, difficulty speaking, and blurred vision. The health care provider diagnoses a stroke-in-evolution. Why does the nurse have the client perform a hand squeeze? to determine the client's ability to follow simple commands to determine if the client is right- or left-handed to determine the client's orientation to person to obtain the client's response to pain

to determine the client's ability to follow simple commands The nurse should ask the client diagnosed with a stroke-in-evolution to squeeze the nurse's hand to evaluate the ability to follow commands, thereby determining level of consciousness. It also allows the nurse to evaluate the strength of the client's grip. The client's handedness reflects the dominant side of the brain and would be determined during the client history. Orientation to person is determined by the client's recognition of himself and others. Asking the client to squeeze the nurse's hand would not induce pain. Since the client's level of consciousness is only slightly diminished, eliciting a pain response would not be necessary.

The nurse correctly identifies which as belonging to the dorsal cavity? mouth mediastinum vertebral canal reproductive organs

vertebral canal The dorsal cavity is divided into the cranial (skull) and vertebral canal (spinal cavity). The mediastinum and reproductive organs are located in the ventral cavity. The mouth is located in the oral cavity.

A school nurse is obtaining data from a student at an elementary school. Which finding would lead the nurse to suspect impetigo? vesicular lesions that ooze, forming crusts on the face and extremities red spots with a blue base found on the buccal membranes a discrete, pink-red, maculopapular rash that starts on the head and progresses down the body small, red lesions on the trunk and in the skinfolds

vesicular lesions that ooze, forming crusts on the face and extremities Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most often on the face and extremities. Small, red lesions on the trunk and in the skinfolds are characteristic of scarlet fever. A discrete, pink-red, maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik spots, are characteristic of measles (rubeola).

A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage? restlessness, confusion, increased urine output, and warm, dry skin weak, irregular pulse; cool, moist skin; and hypotension cyanosis, nausea, vomiting, and constricted pupils even, unlabored respirations; tachycardia; and hemoptysis

weak, irregular pulse; cool, moist skin; and hypotension A weak, irregular pulse; cool, moist skin; and hypotension are all signs of hemorrhage in a client who underwent a nephrectomy. Hemorrhage may also cause cyanosis, nausea, vomiting, and dilated (not constricted) pupils. Although hemorrhage produces tachycardia and hemoptysis, it usually results in irregular, labored respirations rather than even, unlabored ones. Hemorrhage also results in restlessness and confusion, along with decreased urine output and skin that is cool and moist.