Test 1 Practice Questions

The nurse is performing an assessment of a client's abdomen. Upon palpation, the nurse feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The nurse is likely palpating which of the following? 1. Inflamed spleen 2. Enlarged liver 3. Inflamed appendix 4. Bilious gallbladder

1.Inflamed spleen Rationale: The spleen is located in the LUQ. If it is enlarged or inflamed it will be extremely painful for the client. The nurse must be careful because the spleen could burst upon palpation. Option 2: The appendix is located in the right lower quadrant. Option 3: The liver is located in the right upper quadrant. Option 4: The gallbladder is located in the right upper quadrant.

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. collects subjective data 2. applies a framework to the collected data 3. confirms data are complete and accurate 4. records data in the client record

3. confirms data are complete and accurate Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity, a framework is applied to the data in the organizing activity, and data is recorded in the documenting activity.

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to the diagnoses." 4. "How is your family responding to the diagnoses?"

3."Tell me about your reactions to the diagnoses." Rationale: Eliciting feelings requires an open-ended question that does more than seek factual information and cannot be answered with a single word. The family can provide indirect information about the client, but is not most likely to provide the most accurate information.

What defines social space?

4-12 ft

The client made the following statement to the nurse, "My doctor just told me that he cannot save my leg and that I need to have an above-the-knee amputation." Which response by the nurse is most appropriate? 1. "Dr. Jones is an excellent surgeon." 2. "Are you in pain?" 3. "If I were you, I'd get a second opinion." 4. "Tell me more. . . ."

4. "Tell me more. . . . " Rationale: Option 4 is a therapeutic technique using an open-ended question that allows the client to elaborate. The other options are barriers to communication. Option 1 is incorrect because the client did not ask about the abilities of the surgeon and the response does not focus on the client. Option 2 is changing the subject, and option 3 is giving advice.

A nurse is palpating a client's abdomen to check for an abdominal aortic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding? 1. The pads of the fingers 2. The ball of the hand 3. The dorsum of the hand 4. The palmar surface

1. The pads of the fingers Rationale: When assessing a client through palpation, the nurse may use different parts of the hand to find differing signs related to the client's condition. The pads of the fingers are best used for palpating pulsations such as with an abdominal aortic aneurysm, edema, and crepitus, as well as determining moisture content of the skin.

The most effective nursing action for controlling the spread of infection includes which of the following? 1. Thorough hand cleansing 2. Wearing gloves and masks when providing direct patient care 3. Implementing appropriate isolation precautions 4. Administering broad-spectrum prophylactic antibiotics

1. Thorough hand cleansing Rationale: Since the hands are frequently in contact with patients and equipment, they are the most obvious source of transmission. Regular and routine hand cleansing is the most effective way to prevent movement of potentially infective materials. Option 2: PPE (gloves and masks) is indicated for situations requiring Standard Precautions. Option 3: Isolation precautions are used for patients with known communicable diseases. Option 4: Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms.

The activation of pain receptors is what phase? 1. Transduction 2. Transmission 3. Modulation 4. Perception

1. Transduction

The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, "I am so dizzy I can't stay standing up." What is the nurse's first priority? 1. Vital Signs 2. Full neurological exam 3. Draw blood 4. Get an EKG (ECG)

1. Vital Signs Rationale: The nurse will prioritize using the ABCs, or airway, breathing, then circulation. However, while obtaining vital signs, the nurse will also notify the provider to get an EKG (ECG). The EKG will happen right after vital signs are obtained.

A major characteristic of the nursing process is which of the following? 1. a focus on client needs 2. its static nature 3. an emphasis on physiology and illness 4. its exclusive use by and with nurses

1. a focus on client needs Rationale: The nursing process focuses on client needs. It is dynamic rather than static, emphasizes client responses rather than physiology or illness, and is collaborative rather than used exclusively by nurses.

The nurse who uses appropriate therapeutic listening skills will display which behaviors? Select all that apply. 1. Absorb both the content and the feeling the client is conveying. 2. Presume an understanding of the client needs. 3. Adopt an open professional posture. 4. React quickly to the message. 5. Reassure the client that everything will be fine.

1. Absorb both the content and the feeling the client is conveying. 3. Adopt an open professional posture. Rationale: Options 1 and 3 are listening behaviors. Options 2,4 and 5 are barriers to listening.

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. identifying major problems or needs 2. organizing data in the client's family history 3. establishing short term and long term goals 4. administering an antibiotic

1. identifying major problems or needs Rationale: Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have impaired gas exchange related to a constricted airway as manifested by shortness of breath (dyspnea) as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is part of the planning phase. Administering an antibiotic is part of the implementation phase.

What defines personal space?

1.5-3 ft

What defines intimate space?

0-1.5 ft

It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel? 1. A client being prepared for elective facial surgery with a history of stable hypertension. 2. A client receiving a blood transfusion with a history of transfusion reactions. 3. A client who recently started on a new anti-arrhythmic agent. 4. A client who is admitted frequently with asthma attacks.

1. A client being prepared for elective facial surgery with a history of stable hypertension. Rationale: Vital signs measurement may be delegated to UAP if the client is in stable condition, the findings are expected to be predictable, and the technique requires no modification. Only the preoperative client meets these requirements. In addition, UAP are not delegated to take apical pulse measurements for the client with an irregular pulse as would be the case with the client newly started on antiarrhythmic medication (option 3).

In which situation would it be most appropriate to perform a comprehensive health history assessment on a client? 1. A client is being seen for complaints of fatigue 2. A client is seeking care for a broken arm 3.A client needs an adjustment on his asthma medications 4.A client is being seen for a follow-up appointment after surgery

1. A client is being seen for complaints of fatigue Rationale: A comprehensive health history assessment collects data about the client's entire health history and any medications, surgical procedures, or family health issues that are present. It is most appropriate when the provider does not know the client, such as when a new client is seen at a health clinic, or when the client needs help with a general concern that could have many causes, such as fatigue. A focused assessment concentrates on the client's current issue, while a follow-up assessment is important after a client has been seen for the same issue.

Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status 2. Identify client strengths and problems 3. Develop an individualized plan of care 4. Implement care, prevent illness, and promote wellness

1. Establish a database of client responses to his or her health status Rationale: Assessing provides a database of the client's physiological and psychological responses to his or her health status. Client strengths and problems are identified in the diagnosing phase of the nursing process, a care plan is established in the planning phase, and care, prevention, and wellness promotion are part of the implementation process.

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1. Goggles 2. Gown 3. Surgical mask 4. Clean gloves

1. Goggles Rationale: Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused.

The nurse asks the client, "What do you fear most about your surgery tomorrow?" This is an example of which communication technique? 1. Providing general leads 2. Seeking clarification 3. Presenting reality 4. Summarizing

1. Providing general leads Rationale: It encourages the client to verbalize and choose the topic of conversation. Option 2 is used when the nurse is unsure of the message and asks the client to restate the message. Option 3 is used to help a client differentiate the real from the unreal, and there is no information available to indicate this is a concern in this situation. Option 4 is used at the end of an interview or teaching session.

A nurse tells a client who is struggling with cancer pain, "It is normal to feel frustrated about the discomfort." Which is most representative of the skills associated with the working phase of the helping relationship? 1. Respect 2. Genuineness 3. Concreteness 4. Confrontation

1. Respect Rationale: Respect is correct because the nurse is validating the client's feeling. It is not option 2 (genuineness) bc the nurse is giving information versus being genuine. Option 3 (concreteness) is giving a specific example, and the nurse is not confronting (option 4) but supporting through respect for the client's feelings.

When listening to a client's heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope? 1. S3 2. S1 3. High-frequency murmurs 4. S2

1. S3 Rationale: There are two sides of the stethoscope that the nurse may use with auscultation: the bell and the diaphragm. The bell side is used to hear low-pitched sounds, while the diaphragm is used for high-pitched sounds. The bell is used to assess the S3 and S4 heart sound, as these are low-pitched sounds.

What defines public space?

12 ft and beyond

When auscultating the blood pressure, the nurse hears: From 200 to 180 mmHg: silence then: a thumping sound continuing down to 150 mmHg: muffling sounds continuing down to 130 mmHg; soft thumping sounds continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg; then silence. The nurse records the blood pressure as __________________

180/105/95

While at a routine clinic appointment, the nurse notes a client with lung cancer is breathing heavily, wearing dirty clothes, and looking disheveled. The client has lost 15 pounds since the last visit. Which of the following statements by the nurse therapeutically assesses the client's functional capacity? Select all that apply. 1. "Have you noticed that you are more short of breath than usual lately?" 2. "Can you tell me how you are doing at home managing your daily activities?" 3. "Tell me more about your support system at home" 4. "I am going to arrange for someone to come to your home to wash your clothes" 5. "I am going to contact the social worker since you can't afford to purchase food"

2. "Can you tell me how you are doing at home managing your daily activities?" 1. "Have you noticed that you are more short of breath than usual lately?" 3. "Tell me more about your support system at home" Rationale: Option 2: This allows the client to speak to their functional capacity and ability to complete their activities of daily living. This question allows the nurse to assess how the client's cancer and treatment regimen is affecting the client's ability to meet his/her own needs. Option 1: Both the disease process and treatment regimen in lung cancer can negatively impact the client's respiratory status and is a common reason that the client struggles to complete ADLs. Option 3: This is an open-ended question that will allow the nurse to assess the client's resources and support network.

The nurse is communication with a primary care provider about medical interventions prescribed for a client. Which statement is most representative of a collaborative relationship? 1. "That new medication you prescribed for Mr. Black is ineffective." 2. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensive medication." 3. "Can we talk about Mr. Black?" 4. "Excuse me doctor. I think we need to talk about Mr. Black's blood pressure."

2. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensive medication." Rationale: Option 2 uses an "I" statement, which is assertive communication and is clear and direct. The message includes only the necessary information. Option 1 contains inflammatory language ("ineffective" and "you prescribed"). Options 3 and 4 do not provide the health care provider with specific information and could stimulate defensive behaviors.

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene? 1. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." 2. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." 3. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." 4. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

2. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." Rationale: Nursing assessment date are used only to provide information about the effectiveness of your medical care. Think HIPA

For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? 1. 10-20 seconds 2. 30-45 seconds 3. 1-1.5 minutes 4. 3-3.5 minutes

2. 30-45 seconds Rationale: If the cuff is inflated to about 30 mmHg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid-60s mmHg (and then completely) for someone with a previous reading of 74. The cuff should be deflated at a rate of 2 to 3 mm per second. Thus, a range of 90 mmHg will require 30 to 45 seconds.

After being admitted for emergency surgery, an 80 year old client has just returned to the room from the PAR (postanesthesia room). Which nursing interventions are most likely to facilitate effective communication with this client? Select all that apply. 1. Ask the client, "Do you know where you are." 2. Ask the client or support person about visual or learning problems. 3. Inform the client and support person(s) about events likely to occur during the next 2 hours. 4. Provide the client with instructions about discharge. 5. Tell the client, "You will feel better soon."

2. Ask the client or support person about visual or learning problems. 3. Inform the client and support person(s) about events likely to occur during the next 2 hours. Rationale: Assessing possible visual or hearing problems allows the nurse to provide appropriate interventions. (i.e. inserting hearing aid) Communicating what will be occurring at a stressful time helps the client feel more secure and can reduce anxiety. Option 1 is not the best answer as the client could say yes/no or not the head and the nurse will not know if the client fully understands.

The client's temperature at 8:00 am using an oral electronic thermometer is 36.1 degrees C (97.2F) If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next? 1. Wait 15 minutes and then retake it. 2. Check what the client's temperature was last time it was taken. 3. Retake it using a different thermometer. 4. Chart the temperature, it is normal.

2. Check what the client's temperature was last time it was taken. Rationale: Although the temperature is slightly lower than expected for the morning, it would be best to determine the client's previous temperature range next. This may be a normal range for this client. Depending on that finding, the nurse might want to retake it in a few minutes—no need to wait 15 minutes (option 3) or with another thermometer to see if the initial thermometer was functioning properly. Chart after determining that the temperature has been measured properly (option 4).

The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? Select all that apply. 1. Prescription medications for heart failure 2. Clean appearance 3. Complaints of abdominal pain 4. Height and weight 5. Cooperative behavior

2. Clean Appearance 4. Height and weight 5. Cooperative behavior Rationale: Option 2: Evaluating the appearance of a client is part of the general survey. Option 4: Height and weight is part of the general survey of a client. Option 5: The general survey is the initial part of the assessment performed by the nurse. This is an overall review and first impression the nurse gets of the client's well-being. It includes behavior, appearance, and body structure/mobility. It is necessary for the nurse to make a clinical judgment as a baseline for concerns that will arise and direction of the nursing care plan.

Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes 2. Ensure that no one can overhear the interview conversation. 3. Stand near the client's head while he or she is in the bed or chair. 4. Keep approximately 3 feet from the client during the interview 5. Use a standard form to be sure all relevant data are covered in the interview.

2. Ensure that no one can overhear the interview conversation. 4. Keep approximately 3 feet from the client during the interview 5. Use a standard form to be sure all relevant data are covered in the interview. Rationale: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information. Lighting should be at normal level. The nurse should be at the same height as the client, usually sitting, at approximately 45 degree angle facing client. The nurse standing over the client creates an uncomfortable atmosphere for an interview.

A depressed client who has not bathed or dressed in clean clothes today is reading the lunch menu but is unable to make a decision. Which would be the most appropriate nursing diagnosis for this client? 1. Anxiety 2. Powerlessness 3. Chronic Low Self-Esteem 4. Social Isolation

2. Powerlessness Rationale: Because anxiety and low self- esteem precede powerlessness, which results in indecisiveness, it is the most correct answer. Nursing management always deals with the client's current display of needs. Options 1 and 3 may cause a sense of powerlessness that results in indecisiveness. Option 4: there is not evidence that the client's social interactions are less than adequate.

A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. During the client interview, the nurse wants to assess the client's background and health history. Which of the following are examples of leading questions that the nurse should avoid? Select all that apply. 1. You feel pretty good right now, right? 2. You don't miss doses of your medication, do you? 3. Who do you live with? 4. Do you have a history of heart disease? 5. Where are you working right now?

2. You don't miss doses of your medication, do you? 3. You feel pretty good right now, right? Rationale: Option 2: This is not an appropriate question. Leading questions are those given by the nurse that would suggest that there is a right or wrong answer. The question, "You don't miss doses of your medication, do you?" implies that the client would be wrong if he or she did not take the medicine every day. The nurse should avoid leading questions when taking a client history in order to not influence the client's answers. Option 3: This is not an appropriate question. The question, "You feel pretty good right now, right?" implies that the client would be wrong if he or she did not feel good. The nurse should avoid asking this question.

Which of the following elements is best categorized as secondary subjective data? 1. the nurse measures a weight loss of 10 pounds since the last clinic visit 2. spouse states the client has lost all appetite 3. the nurse palpates edema in lower extremities 4. client states severe pain when walking upstairs

2.spouse states the client has lost all appetite Rationale: Primary data comes from the client whereas secondary data may come from another source (family, chart, etc). Subjective data are covert (reported or an opinion) whereas objective data can be measured or validated (weight or palpating edema)

Place the following descriptions of the helping relationship phases in the correct sequence. 1. After introductions, the nurse asks, "What plans do you have for the upcoming holiday weekend?" 2. The nurse states, "It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?" 3. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago. 4. The nurse states, "When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situations."

3, 1, 2, 4 Rationale: During the preinteraction phase, (option 3), the nurse gathers information about the client before meeting the client. During the introductory phase (option 1) the nurse usually engages in some social interaction to put the client at ease. During the working phase (option 2) the nurse helps the client to explore feelings and helps the client plan a program. During the termination phase (option 4), the nurse summarizes or reviews the process that took place.

The nurse is communicating with a well oriented older adult client in a long term care setting. Which statement best reflects respectful and caring communication? 1. "Are we ready for our shower?" 2. "It's time to go to the dining room, honey." 3. "Are you comfortable, Mrs. Smith?" 4. "You would rather wear the slacks, wouldn't you?"

3. "Are you comfortable, Mrs. Smith?" Rationale: All of the other options are forms of elderspeak.

Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse? 1. A client who is in shock 2. A client whose pulse changes with body position changes 3. A client with an arrhythmia 4. A client who had surgery less than 24 hours ago

3. A client with an arrhythmia Rationale: The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an arrhythmia. For clients in shock, use the carotid or femoral pulse (option 1). The radial pulse is adequate for determining change in orthostatic heart rate (option 2). The radial pulse is appropriate for routine postoperative vital sign checks for clients with regular pulses (option 4).

A student nurse is caring for a 72-year-old client with Alzheimer's disease who is very confused. Which is the most appropriate communication strategy to be used by the student nurse? 1. Written directions for bathing 2. Speaking very loudly 3. Gentle touch while providing ADLs 4. Flat facial expression

3. Gentle touch while providing ADLs Rationale: Nonverbal, gentle touch is an important tool; overstimulation may affect the client in a negative way. Option 1: written communication requires a higher level of consciousness than verbal. Option 2: the client does not have a hearing problem but lacks the ability to interpret and understand communication. Option 4: lack of facial expression may increase fear.

A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client's respiratory rate? 1. Administer oxygen via non-rebreather mask 2. Remove oxygen and assess the client's pulse oximetry 3. Prepare for intubation 4. Administer oxygen via nasal cannula

3. Prepare for intubation Rationale: The Glasgow Coma Scale is a method of determining the neurological state of a client who has suffered an injury that could impact brain function. The lower the level determined with the GCS, the more likely the client has a significant brain injury and is most likely unconscious and not responding. A GCS score less than 9 indicates that the client is impaired enough that he may not be able to breathe on his own without assisted ventilation. When the score is less than 9, the nurse should prepare for intubation (which will be at the discretion of the provider).

The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following? 1. Shallow respirations 2. Wheezing 3. Shortness of breath 4. Coughing up blood

3. Shortness of breath Rationale: Dyspnea, difficult or labored breathing, is commonly related to inadequate oxygenation. Therefore, the client is likely to experience shortness of breath, that is, a sense that none of the breaths provide enough oxygen and an immediate second breath is needed. Option 1: Shallow respirations are seen in tachypnea (rapid breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may not occur with dyspnea. Option 4: The medical term for coughing up blood is hemoptysis and is unrelated to dyspnea

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1.Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3 Provide a bedside commode. 4. Keep the side rails up.

3.Provide a bedside commode. Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

An 85 year old client has had a stroke resulting in right sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply. 1. oral 2. rectal 3. axillary 4. tympanic 5. temporal artery

3.axillary 4.tympanic 5.temporal artery Rationale: For this client, the nurse could take an axillary, tympanic, or temporal artery temperature. Due to the facial drooping and difficulty swallowing, the oral route is not recommended (option 1). Although the rectal route could be used, it would require unnecessary moving and positioning of a client who cannot assist, and it would not provide a significant advantage over the other routes (option 2).

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. proposes hypothesis 2. generates desired outcomes 3. reviews results of laboratory tests 4. documents care

3.reviews results of laboratory tests Rationale: During assessment, data are collected, organized, validated, and documented. Hypothesis are generated during diagnosing, outcomes are set during planning, and documentation occurs throughout the nursing process.

A nurse is counseling an 87-year-old female patient and her daughter. The patient is obese, has multiple medical problems, including dementia, and takes numerous medications. The patient is preparing to move in with her daughter for full-time care. Which of the following is least important for the nurse to discuss with the patient and her daughter. 1. Side effects of her medications 2. Proper ergonomics for lifting/assisting the patient in her activities of daily living 3. Fall prevention and safety 4. Fire safety and prevention

4. Fire safety and prevention Rationale: While fire safety and prevention is certainly a worthwhile topic to discuss, given this patient's particular set of problems of obesity, polypharmacy, dementia, and advanced age, the other choices should take priority during the review of safety and accident prevention.

A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client? 1. Semi-Fowler's 2. Sims' position 3. Dorsal recumbent 4. High Fowler's

4. High Fowler's Rationale: To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler's position. In this position, the client is sitting up with the head of the bed at a 90-degree angle. The high Fowler's position is used for performing an assessment that would require the client to sit up, such as the face and head, chest, and back.

The nurse at a family practice is responsible for reviewing home safety issues with all patients. She knows that there is an increased risk of falls in which of these two groups of patients? 1. The elderly and school-age children 2. Toddlers and the elderly 3. Infants and toddlers 4. Infants and the elderly

4. Infants and the elderly Rationale: Infants and the elderly both have increased risk of falls. Nurses should educate the parents and/or caregivers of infants about safe places for sleep and play to prevent a fall. In the elderly, nurses must consider age-related factors, both physical and cognitive that can increase the risk of falling.

Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense 2. Observing is done only when no other nursing interventions are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any particular order. 4. Observed data should be interpreted in relation to other sources of collected data.

4. Observed data should be interpreted in relation to other sources of collected data Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities. A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first.

When the nurse enters a client's room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate? 1. Count the respirations during conversational pauses. 2. Ask the client to end the phone call now and resume it at a later time. 3. Wait at the client's bedside until the phone call is completed and then count respirations. 4. Since there is no evidence of distress or urgency, postpone the measurement until later.

4. Since there is no evidence of distress or urgency, postpone the measurement until later. Rationale: Since the client's needs are always considered first, the measurement should be delayed unless the client is in distress or there are other urgent reasons. Option 1: Respirations should be measured for 30 seconds to 1 minute and are affected by talking. Option 2: There needs to be an important reason for interrupting the client. Option 3: It is inappropriate to wait and listen to the client's conversation.

A nursing diagnosis of ineffective peripheral tissue perfusion would be validated by which one of the following? 1. bounding radial pulse 2. irregular apical pulse 3. carotid pulse stronger on the left side than right 4. absent posterior tibial and pedal pulses

4. absent posterior tibial and pedal pulses Rationale: The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are central and not peripheral.

The use of conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health team. 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care. 4. Collection of all necessary information for a thorough appraisal.

4.Collection of all necessary information for a thorough appraisal. Rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate. Cost effective care plan is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured.