Week 1: Basic Physical Assessment

A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?

"I should drink more water when feeling thirsty or becoming irritable." Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs. Dehydration is a problem at all times, not just when it's hot outside. Lotion helps dry skin, but will not help hydration.

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:

respiratory acidosis. Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first?

Use a Doppler ultrasound device. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse is not palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the HCP may be necessary if there is a change in the client's condition.

While examining the hands of a client with osteoarthritis, a nurse notes Heberden's nodes on the second (index) finger. Identify the area on the finger where the nurse observed the node.

Heberden's nodes appear on the distal interphalangeal joints. Bouchard's nodes appear on the proximal interphalangeal joints. These bony and cartilaginous enlargements are usually hard and painless and typically occur in middle-aged and elderly clients with osteoarthritis.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?

carotid During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) are no longer palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

A client asks the nurse why the prostate-specific antigen (PSA) level is determined before the digital rectal examination. What should the nurse tell the client?

"A prostate examination can possibly increase the PSA." Manipulation of the prostate during the digital rectal examination may falsely increase the PSA levels. The PSA determination and the digital rectal examination are no longer recommended as screening tools for prostate cancer. Prostate cancer is the most common cancer in men and the second leading killer from cancer among men in the United States and Canada. Incidence increases sharply with age, and the disease is predominant in the 60- to 70-year-old age group.

Which assessment question is most likely to yield clinically meaningful data about a female client's sexual identity?

"How do you feel about yourself as a woman?" Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the client feels about herself as a woman is likely to elicit important insights. Assessing the client's history of STIs does not directly address her sexual identity.

What should the nurse include in the teaching plan for the family of a newborn receiving home phototherapy? Select all that apply.

"The lights should be 12 to 30 inches (30 to 76 cm) above your newborn." "Record your newborn's temperature, weight, and fluid intake daily." "Make sure your newborn's eyes are covered well when under the lights." In home phototherapy, lights should be kept 12 to 30 inches (30 to 76 cm) from the newborn. The caregiver should record the newborn's temperature, weight, and fluid intake daily. The newborn's eyes should be covered well under the lights. The newborn does not have to stay under the lights all the time. The newborn can come out for feeding and bonding. The newborn should be naked except for a diaper when under the lights.

The nurse enters the hospital room and finds the client unresponsive to verbal stimulation. What would be the next action by the nurse?

Apply physical stimulation. During a rapid assessment, the nurse's first priority is to check the client's responsiveness. If it is determined there is no response, further assessment is needed. Open the airway, assess for breathing, then assess for circulation. To check circulation, the nurse must assess a client's heart and vascular network function by checking the client's skin color, temperature, mental status and, most importantly, pulse. The nurse would use the carotid artery to check a client's pulse. In a client with a circulatory problem or a history of compromised circulation, the nurse may not be able to palpate the radial pulse. The nurse palpates the brachial pulse during rapid assessment of an infant.

A client has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

Assess the blood pressure in the supine, sitting, then standing positions. By measuring the client's blood pressure in the supine, sitting, and standing positions, the nurse can assess for postural hypotension. Asking the client to ambulate first and taking the blood pressure on both arms will not provide the most accurate information. Assessing at the beginning and end of the exam is incorrect because this measures a deficit and is not a tool for investigating hypotension.

The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. What should the nurse do next?

Check the client's baseline data. The nurse should check the client's baseline data to ascertain whether the client's pupil has always been enlarged or this is a new finding. The preoperative assessment is valuable as the baseline for comparison of all subsequent assessments made throughout the perioperative period. The nurse may determine that a more involved neurologic examination is indicated or may choose to assess other signs using the Glasgow Coma Scale, administer oxygen, or call the surgeon, but the nurse still needs to know the baseline data before proceeding.

The surgical floor receives a client from the postanesthesia care unit. Ten minutes ago, the final assessment in the postanesthesia care unit indicated that the client had a patent airway and stable vital signs. The client's pain level was 2. What should the nurse do next?

Check the dressing for signs of bleeding. The nurse should check the dressing for signs of bleeding to establish a baseline for future assessments of the dressing and to verify that there is no obvious sign of hemorrhage. The nurse does not need to empty peri-incisional drains at this time. All drains should have been emptied and reconstituted by the postanesthesia care nurse before the client was transferred to the surgical floor. Assessing the client's pain level and assessing the bladder are important; however, it is more important to assess the surgical site for bleeding because hemorrhage is a life-threatening complication of any surgical procedure.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). What should the nurse do next?

Encourage the client to increase fluid intake. The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.

Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. SBAR communication stands for Situation, Background, Assessment, and Recommendation. The nurse must first state the nurse's name and location. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.

The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment?

Keep the client warm. Vasodilation or vasoconstriction will affect the assessment findings in a client with PVD, so the nurse would keep the client warm. The nurse would keep the client covered and expose only the portion of the client's body that the nurse is assessing. The nurse would also keep the client warm by maintaining the room temperature between 68°F and 74°F (20° and 23.3°C). Extreme temperatures have a negative effect on clients with PVD. Keeping the client uncovered would cause the client to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia. The nurse must palpate the carotid arteries 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 could lead to cardiac arrest.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx. To assess a client's gag reflex, the nurse should gently touch the posterior aspect of the pharynx with a tongue blade, which should elicit gagging. Having the client say "ah" allows the nurse to evaluate cranial nerves IX and X. However, the nurse needn't use a tongue blade to hold down the tongue; the client need only stick out their tongue. Placing a tongue blade on the middle of the tongue and asking the client to cough has no value. Placing a tongue blade on the uvula may traumatize the area and harm the client.

A nurse is assessing a client with pneumonia. The nurse asks the client to say "99." What is the nextaction by the nurse?

Place the ulnar surface of the hand on the chest to detect vibration The nurse is assessing tactile fremitus (vibratory tremors that are felt through the chest on palpation while the client speaks). The nurse uses the ulnar surface (palm) of the hand to assess tactile fremitus. Tactile fremitus increases with dense or inflamed lung tissue, which occur with pneumonia. The fingertips and finger pads best distinguish texture and shape. The dorsal surface is most sensitive to warmth. Neither of these would be beneficial in assessing tactile fremitus. Assessing for chest movement is not part of this assessment.

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release. The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The nurse doesn't use light palpation or deep palpation or maintain fingertip contact with skin to elicit rebound tenderness.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first?

Take the client's blood pressure. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint?

assessing the painful area last Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when the nurse will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). What would the nurse determine is the cause of this sound?

closing of the aortic and pulmonic valves The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate?

coughing when drinking liquids In Parkinson disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. Early Parkinson disease is characterized by unilateral upper extremity weakness and tremors. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired, and coughing would indicate aspiration.

The nurse is preparing a client for an MRI after trauma to the spinal column. Which item(s) must be removed prior to the client undergoing this procedure? Select all that apply.

epidural catheter EKG electrodes metal jewelry oximetry probe Metal is prohibited due to the intense magnetic field of the MRI. Caregivers must remove all metal objects for the client prior to taking the client into the scanner room. This will include oximetry probe, EKG electrodes, jewelry, and epidural catheter. Non-colored contact lenses are not contraindicated for the MRI scanner.

A community health nurse is planning to address the primary health needs of older adults living in their homes. What areas would the nurse assess first?

exercise patterns, nutrition, mobility, and safety Assessing exercise patterns, nutrition, mobility, and safety provides teaching regarding health promotion and illness and injury prevention for elderly clients living in their homes. It is important to ensure that elderly clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for elderly clients. Assessment of falls, injuries, and rehabilitation focuses only on mobility. Disease identification and management are important but do not address the most important factors that allow elderly clients to remain safe in their own homes. Medical visits are important, but they focus on health problems more than on meeting physical needs.

The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should

expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 5 minutes, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds.

A client with a spinal cord injury says they are having difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury?

fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client?

lactose enzyme deficiency Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population and suicide is a common health problem for the Native American and white middle-class populations.

A client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation?

metabolic acidosis The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3-level is decreased. These findings indicate that the client is in metabolic acidosis.

The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being:

midline. The umbilicus is midline. The umbilicus is not inflamed or everted (protruding). There is no evidence of a hernia.

A nurse is caring for a client during barbiturate therapy. The client receiving this drug should be evaluated for which condition?

physical dependence Clients can become dependent on barbiturates, especially with prolonged use. Barbituates do not cause increased bleeding time, but may be combined with aspirin, which would be contraindicated in a client with prolonged bleeding time. Barbiturates are absorbed well and do not cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs.

After a local factory explodes, a nurse begins to triage the victims. Victim 1 is unconscious and not breathing. After opening the victim's airway, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds but remains unconscious. What color tag should the nurse use for this victim?

red The nurse should us a red tag for this client. The red tag is for those who require medical attention within 60 minutes for survival including compromise to airway and breathing. Yellow tags are for serious and potentially life-threatening injuries, but the client's status is not expected to deteriorate significantly over the next several hours. Green is a victim with relatively minor injuries whose status is unlikely to deteriorate over time and may be able to assist in one's own care. Black tags include deceased victims, victims unlikely to survive due to the severity of injuries, level of available care, or both. Palliative care and pain relief should be provided.

A nurse is caring for a client who reports consuming 12 alcoholic beverages per day. For which symptoms will the nurse monitor related to this information?

seizures and hallucinations A client who reports consuming 12 alcoholic beverages per day would be monitored for symptoms of acute alcohol withdrawal. Symptoms of acute alcohol withdrawal include seizures and hallucinations. The seizure threshold is lowered in the brain with acute alcohol withdrawal. Hallucinations are associated with magnesium deficiency and other electrolyte imbalances associated with acute alcohol withdrawal. The client would more likely be hypertensive and tachycardic. Aphasia and ataxia are reflective of a stroke. Bleeding and ascites are reflective of liver failure

The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessments? Select all that apply.

suicide or self-harm ideation recent use of substances of abuse allergic reactions or adverse drug reactions When assessing client safety, the nurse assesses suicide thoughts or plan, recent use of illicit drugs (as they may cause impaired judgment or thought processes), and previously experienced allergic reactions and adverse reactions to medications. Note that safety involves many aspects of care. Incentives and diet preferences (allergies would be previously noted) are not directly related to safety, although they may be part of an overall assessment.

A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases?

tachypnea Hyperventilation/tachypnea leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli?

tactile This client is responsive to tactile stimulation, because the client responded when the nurse touches the skin. Spontaneous response would refer to the client who was awake, alert, and required no intervention on the nurse's part to elicit a response. If the client had responded to the nurse saying the client's name, this would be a response to verbal stimuli. The client does not require painful stimuli, such as nail bed pressure, trapezius squeeze, or sternal rub, to get a response.

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

temporal The temporal lobe controls hearing, language comprehension, and storage and recall memory. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

A client of African descent is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which area would the nurse check for pallor in the client?

tongue In a client of African decent, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas may have heavy pigmentation.

A mother comes to the clinic with her 5-year-old child who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're

touching the uvula. Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are rated 4+.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

vesicle A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply.

vital signs skin color urine output peripheral pulses Shock is a medical emergency in which the organs and tissues of the body are not receiving adequate blood flow. Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys and peripheral pulses all provide assessment data relating blood volume and circulation. Nutrition and gait are not related to blood circulation.

The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately?

"I took my metformin this morning." The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

The nurse is working in a public health clinic. Four clients present with various skin disorders. Which disorder requires disclosure to public health officials?

Picture 3 is a Rubella (German Measles) rash. Rubella is a contagious viral infection known for its distinctive red rash. Due to vaccines, it is not seen often but is still classified as a communicable disease. Titers are drawn to document immunity. Picture 1 is poison ivy characterized by the red raised and sometimes fluid-filled vesicles. Picture 2 is a butterfly rash commonly seen in the autoimmune disease Lupus. Picture 4 is the bull's-eye rash commonly seen in Lyme's Disease.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

A nurse is working in the intermediate care unit. After receiving change of shift report who should the nurse assess first?

a client with aortic stenosis who has a blood pressure of 84/52 mm Hg Hypotension in a client with aortic valve problems can indicate cardiogenic shock. The nurse should assess this client for other symptoms such as dyspnea or chest pain. The other clients are experiencing expected symptoms of their medical diagnosis and are in no acute distress.

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess?

changes from the normal expected findings Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status.

While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do?

Ensure that the room is kept warm. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric reflex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should warm the hands and make sure that the environment also is warm. Checking the diaper for urination provides information about the infant's voiding and urinary function, not information about the testes. Giving the infant a pacifier may help to calm the infant and possibly make the examination easier, but the concern here is with the temperature of the environment. Tapping on the inguinal ring would not be helpful in assessing the infant.

The nurse has just received report on four clients. Which client should be seen first?

a client feeling sweaty and requesting antacid for stomach upset Signs of indigestion and sweating can be signs of impending myocardial infarction that should be carefully assessed by the nurse. The client who had the cardiac catheterization has stable vital signs and should be reassessed after assessing the client with a potential impending myocardial infarction. The client who had respiratory therapy does not require immediate attention. The client with diabetes has a normal finger stick glucose level and does not require immediate attention.

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

acute respiratory distress syndrome pneumonia pulmonary edema Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

The nurse is performing a nutrition assessment of a client from the Middle East. What may the nurse expect as a traditional breakfast consumed by a client from the Middle East?

cheese and olives People from Middle Eastern countries often eat cheese and olives for breakfast.

Which is the highest priority action by the nurse before completing this skill?

Assess stomach residual. The picture provided is of a nurse administering a bolus tube feeding. Prior to administration, the highest priority would be to assess tube patency and stomach residual. Both can be accomplished by checking stomach residual. The client is placed in a Fowler's position for feeding, not supine. It is common to flush the tube after patency and residual are assessed. Bowel sounds are assessed as part of a routine assessment.

After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed

Respiratory rate drops from 24 breaths/minute to 16 breaths/minute. Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, increased pulse rate, and bubbling breath sounds indicate respiratory secretion accumulation.

Which statement regarding heart sounds is correct?

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. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's prognosis?

as soon as the client is warmed The neural or hemodynamic status of the client cannot be determined until the client is warmed. The nurse would not have to wait 3 days to do so. Stable blood pressure is important, but the determining factor is the client's core body temperature

Which sound should the nurse expect to hear when percussing a distended bladder?

dullness A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: blood pressure is 148/92 mm Hg. heart rate is 98 bpm. respirations are 32 breaths/min. O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. breath sounds are coarse and wet bilaterally with a loose, productive cough. The client has voided 100 mL very dark, concentrated urine during the last 4 hours. bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription?

diuretic medication The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.

The nurse is assessing a client's testes. Which finding indicate the testes are normal?

egg-shaped Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the health care provider (HCP).

The nurse is assessing the progression of jaundice in a neonate who requires phototherapy. Place the assessment areas in the expected order. All options must be used.

face chest abdomen extremities Jaundice progresses in a cephalocaudal and proximodistal pattern beginning with the face, chest, abdomen, and then extremities. A neonate with a higher level of bilirubin requiring phototherapy will have a more involved area of assessment.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations 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's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider?

urine output of 600mL/24 hours Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.

Which finding will the nurse assess in a client diagnosed with peritonitis?

abdominal wall rigidity Abdominal wall rigidity is a common manifestation of peritonitis. Bowel sounds may or may not be present in peritonitis. A positive Cullen's sign is a manifestation of acute pancreatitis, and Battle's sign is a manifestation of skull fractures.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?

"At first, the stoma may bleed slightly when touched." The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. 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.

When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client?

"Do you wear glasses?" The nurse would ask whether the client wears glasses to evaluate the client's preoperative cognitive-perceptual pattern. Asking about the client's swallowing pattern would evaluate the client's nutritional-metabolic pattern. Asking about the client's need for special equipment to walk would evaluate the client's activity-exercise pattern. Asking about the client's history of smoking would evaluate the client's health perception-health management pattern

Students in a health class are discussing birth control and prevention of sexually transmitted disease. The school nurse would know that teaching has been effective if the students make which statement?

"Responsible sex involves using condoms and spermicides for protection and birth control." This comment indicates an understanding of ways to lessen the incidence of sexually transmitted illnesses by condom use. It also indicates that use of a spermicide and condom will help to prevent unwanted pregnancies. The other choices are not accurate examples of safer sex.

A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications?

"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, or anxiety about surgery wouldn't increase the risk of postoperative complications.

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?

"Just as I get over a virus, it seems that I get another." Immune deficiencies make it harder for the body to fight infection. With a low resistance, the client is susceptible to obtaining more circulating viruses. Having morning stuffiness and a sore throat is indicative of sinus congestion. Having a leg sore is indicative of cardiovascular insufficiency or diabetes. Sneezing with watery eyes is indicates seasonal allergies.

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?

"Tell me what you are feeling." The nurse should ask the client to tell the nurse what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions like "Are you having pain?", "Do you need pain medication?", and "Are you feeling all right?" may block communication.

A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse?

"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." Some research has indicated that a genetic link may be present. Suggesting that the child take aspirin is incorrect because that is offering medical advice and is out of scope of practice of a nurse. Reassuring the client is providing false reassurance.

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?" An open-ended question (one that cannot 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 closed-ended questions. Having the client describe how the pain medication makes them feel does not address the issue of the client's present statement of pain.

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply.

"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 would first find out when the rash began; this can assist with the correct diagnosis. The nurse would 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 would ask about recent travel; exposure to foreign foods and environments that can cause a rash. The client's ethnic background and smoking and drinking habits would not provide further insight into the rash or its cause.

The nurse is preparing to administer fentanyl 25 mcg I.V. The available dose is 100 mcg/2 ml vial. How much medication will the nurse ask another nurse to witness as a waste? Record your answer using one decimal place.

1.5 Fentanyl is a Schedule II controlled substance. Federal law requires close monitoring of this type of medication to prevent diversion and misuse. 25 mcg x 2 ml/100 mcg = 0.5 ml to be given 2 ml - 0.5 ml = 1.5 ml to waste The nurse would ask another nurse to witness the waste of 1.5 ml of medication either down the sink or in the approved pharmaceutical waste container as per the facility policy.

The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN?

Administering a client's tube feeding A tube feeding is within the scope of practice of the LPN/VN. The CNA's scope of practice includes assisting a client to ambulate and reminding a client to use the bathroom. Assessing the oxygenation status is more appropriately completed by the RN.

The nurse is caring for a newborn on phototherapy. What nursing intervention(s) is appropriate to include in the plan of care to prevent the side effects of phototherapy in a newborn with hyperbilirubinemia? Select all that apply.

Assess temperature frequently. Monitor intake and output. Phototherapy can cause loose stools, insensible water loss, and altered thermoregulation as side effects. Appropriate interventions to prevent this are monitoring intake and output and assessing temperature frequently. Even though monitoring bilirubin levels and respiratory status is important, it does not prevent side effects. The infant should not require suppositories.

A client has had hoarseness for more than 2 weeks. What should the nurse do?

Assess the client for dysphagia. Hoarseness occurring longer than 2 weeks is a warning sign of laryngeal cancer. The nurse should first assess other signs, such as a lump in the neck or throat, persistent sore throat or cough, earache, pain, and difficulty swallowing (dysphagia). Gargling with salt water may lead to increased irritation. There is no indication of infection warranting an antibiotic. An oral analgesic would provide only temporary relief of discomfort if hoarseness is accompanied by a sore throat.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and their family should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?

Assess the client's temperature. Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

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.

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?

Assess the vital signs and oxygen saturation levels. The correct response is based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the postanesthesia care unit. Checking the dressing and level of pain are both important but not the priority.

A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols. Assessment of extremities is essential for distal blood flow. Professional responsibility is to follow policies and procedures by the hospital. Family presence can lessen confusion, tied knots do not allow for quick release in an emergency situation, and documentation of a client in this acute state needs to occur more often than once per shift.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

A client who is black reports itching and rashes after consuming shellfish. On examination, the nurse finds a keloid on the client's back. What is the most appropriate action by the nurse?

Consider it as normal. The nurse should consider the appearance of keloids as normal in black clients. Keloids are irregular, elevated, thick scars found commonly in darker-skinned clients. Informing the healthcare provider or requesting biochemical investigations is inappropriate because this condition is not pathologic. Also, keloids are not the result of allergic reactions.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?

ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Diagnostic testing is one source of information leading to a medical diagnosis. It is correct to anticipate cardiac and gastrointestinal studies due to the client's signs and symptoms. An ECG evaluates the report of chest pain, laboratory tests determine anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase, and LD levels are appropriate for a primary cardiac problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

The nurse is screening clients for cancer prevention. Which is the recommended screening protocol for colon cancer in asymptomatic clients who have a low-risk profile?

Fecal occult blood testing should be performed annually after age 50 and up to age 75. The screening protocol recommended by the American and Canadian Cancer Societies for early detection of cancer in asymptomatic people includes: Beginning at age 50, men and women should have fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy every year until age 75 unless determined otherwise by a health care provider (HCP). A diet low in saturated fat and high in fruit and fiber is not a screening protocol but is good dietary advice for all clients.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?

Follow the formal written plan of action for coordinating the response of the hospital staff. When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane?

Grasp the auricle with the nondominant hand, and pull down and back. The ear canal slants up in a younger child and down in an older child or adult. To best visualize the tympanic membrane in an infant, the nurse would grasp the auricle with the nondominant hand and pull down and back to a 6:00 to 9:00 position to straighten the ear canal. The nurse would pull up and back toward a 10:00 position to best visualize the tympanic membrane in an adult or older child. Pulling straight up or down and forward will not be effective in straightening the ear canal as needed for visualization of the tympanic membrane.

At 8 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next?

Immediately notify the healthcare provider of these findings. The nurse would notify the healthcare provider immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse would then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse would sign the preoperative checklist after notifying the healthcare provider of the client's condition and learning whether the provider will proceed with the scheduled surgery.

A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb to the hips. What should the nurse do next? Select all that apply.

Notify the health care provider (HCP) of the change. Place respiratory resuscitation equipment in the client's room. Check for advancing levels of paresthesia. A client who has been admitted for numbness and tingling in the lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The HCP must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing. The family does not need to be called in to visit until the client is stabilized and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the numbness or change the course of the disease.

The nurse notices that the client's temperature over the past 24 hours has risen from 98.8°F (37.1°C) to 101.6°F (38.7° C). The nurse completes a head to toe assessment and documents the nurse's note. What would be the nurse's next nursing action?

Notify the health care provider. When the nurse notes a significant rise in temperature to a febrile status, the nurse must first complete a head to toe assessment to obtain all client data and then notify the health care provider. The health care provider may then opt to assess the client or order diagnostic studies to determine a reason for the rise in client temperature. The nurse would pass the data on to the next shift; however, only the health care provider can order diagnostic testing. Early identification of a problem can lead to subsequent treatment. There is no data that the client is short of breath or oxygen compromised so that oxygen needs to be applied. The nurse would not complete a urine culture without a health care provider's order but could encourage fluids to improve clarity of the urine

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?

Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. The purpose of a registered nurse's signing off the chart is to ensure that the safety of the client has been assessed. Abnormal vital signs identify that priority systems indicate that a stressor or infection is present.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs. The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement.

An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client?

Palpate for a rounded swelling above the pubis. The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity. Dullness does not indicate a distended bladder. The client might experience tenderness or pressure above the symphysis. No urine discharge is expected; the urine flow is blocked by the enlarged prostate

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis. Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

A client presents to the emergency department with liver failure and obvious jaundice. When palpating a client's abdomen, which area would provide the most essential information?

Palpation of the liver in the right upper quadrant would provide essential information on the organ's status. Palpation in a systematic manner identifies masses, enlargement, and degree of tenderness. The nurse can best palpate the liver by standing on the client's right side and placing the nurse's right hand on the client's abdomen, along the right midclavicular line. The nurse would point the fingers of the right hand toward the client's head, just under the right rib margin.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?

Perform a bladder scan, and obtain an order for urinary catheterization. The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.

The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?

Promptly assess the client for potential perforation. A sudden spike in temperature following an endoscopic procedure may indicate perforation of the GI tract. The nurse should promptly conduct a further assessment of the client, looking for further indicators of perforation, such as a sudden onset of acute upper abdominal pain; a rigid, boardlike abdomen; and developing signs of shock. Telling the assistant to change thermometers is not an appropriate action and only further delays the appropriate action of assessing the client. The nurse would not administer acetaminophen without further assessment of the client or without a health care provider's (HCP's) prescription; a suspected perforation would require that the client be placed on nothing-by-mouth status. Asking the assistant to bathe the client before any assessment by the nurse is inappropriate.

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses. Visual acuity is usually measured with a Snellen chart. A client with 20/40 vision is able to read the same sized letters from 20 feet away as a person with "normal" vision would be able to read at 40 feet away. The client with 20/40 vision would be referred to a healthcare provider for the possible need for corrective lenses, as 20/20 vision is considered normal. The client would need to be evaluated by a healthcare provider prior to suggesting the purchase of corrective lenses for reading. In most jurisdictions, 20/40 vision qualifies for an unrestricted driver's license, so corrective lenses may not be required. However, the client must first see the healthcare provider before that can be determined.

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement

Respect the adolescent's wishes and maintain her confidentiality. The nurse should respect the rights of minors who do not want parents informed of medical situations; the nurse should not tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for healthcare visits involving pregnancy, abortion, or sexually transmitted diseases.

The nurse is monitoring a very drowsy client in the immediate postprocedure phase of moderate sedation. The client will open the eyes to repeated verbal stimulation but does not respond verbally. The nurse has an order to give an antiemetic that is known to cause sedation. What assessment tool should the nurse utilize for this client?

Richmond Agitation-Sedation Scale (RASS) The RASS is a standardized tool that helps assess and chart level of sedation or agitation in clients receiving sedating medications. The RASS can help guide health care providers in determining if the client needs more sedation, if the client should not have any more sedating medications administered, or if the client needs intervention because he or she is too deeply sedated to maintain protective reflexes. The RASS can help prevent over- or undersedation in this manner. The CPOT and FLACC scale are tools to assess pain and do not assess sedation nor help prevent oversedation of this client. The MAT is a tool to assess nausea and vomiting in clients receiving anticancer treatments, and would not be appropriate for this client.

The nurse is providing care to a client who was brought to the emergency department by family. The client has full-thickness (third-degree) burns to the face and upper body and is having difficulty speaking. Place these nursing interventions in order the nurse will perform them. All options must be used.

Secure a patent airway Insert a large-bore intravenous cannula Start fluid resuscitation Administer intravenous pain medication Gently cleanse the burns with sterile water Provide psychosocial support to the client and family Clients with burns to the face and upper body are at risk for respiratory and circulatory compromise. The nurse would priorotize airway, breathing, and circulation, then pain control, infection prevention, and psychosocial support. The nurse would first secure a patent airway, start a large-bore intravenous catheter and then begin fluid resuscitation. The nurse would administer pain medication prior to the care of the burns. Psychosocial support would be given after the client is stabilized.

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client?

Take her temperature at the same time every morning before getting out of bed. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F (0.28° C). At the time of ovulation, the temperature rises 0.4°F to 0.8°F (0.22°C to 0.44°C) because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.

Which is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area. When a fingertip is pressed over the reddened area and the area does not blanch but remains consistently reddened, it is an indication of deep tissue injury. The other choices are not appropriate ways to treat a reddened area.

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury?

The client's vital signs will stabilize, returning to normal range. During the acute phase of a neurological injury, the goal of nursing management is to stabilize the client to prevent further neurological damage. A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to normal range. Using adaptive devices would occur in the recovery or chronic phase of a neurological deficit. The client's skin and returning to optimal level of functioning is a goal for later in the recovery process.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable. When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and nonmovable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.

A nurse observes a student auscultating a client's lungs. Which action by the student indicates a need for further instruction on respiratory assessment skills?

The student places the stethoscope over the posterior chest and only listens during inspiration. At each placement of the stethoscope, the student should listen to at least one cycle of inspiration and expiration. All other assessment techniques are correct and do not require additional intervention.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

The nurse is assessing a client's deep tendon reflexes. Which graphic shows assessing the biceps reflex?

To test the biceps reflex, the client's elbow is flexed at a 45° angle. The nurse's thumb or index finger is placed over the biceps tendon and the nurse strikes the digit with the pointed end of the reflex hammer, watching and feeling for the contraction of the biceps muscle and flexion of the forearm. Option A shows assessment of the patellar reflex. Option B shows assessment of the brachioradialis reflex. Option D shows assessment of the triceps reflex.

The charge nurse on a pediatric unit is making clientn assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?

a 4-year-old with chronic graft-versus-host disease who is incontinent The LPN/VN's scope of practice includes care of clients with chronic and stable health problems, such as the client with chronic graft-versus host disease. Chemotherapy medications should be administered by an RN who has received additional education in chemotherapy administration. Platelets and other blood products should be administered by the RN. The 5-year-old client is exhibiting clinical manifestations of neutropenia and sepsis and should be assessed by the RN.

The emergency department (ED) nurse should assess which client first?

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain When the nurse is presented a choice between who to see first, safety and seriousness of the condition are considerations. The individual from the motorcycle accident is stating pain that could indicate internal injuries, a serious complication. This individual would be assessed by the nurse first. Through delegation and prioritization of the remaining clients, the others will have their needs met by the registered nurse and members of the health care team. The nurse identifies physiological jaundice in the 3-day old neonate. Diagnostic lab work will be completed and parental teaching on increasing feedings. A simple dressing on the bleeding laceration could be placed by a licensed practical/vocational nurse or nursing assistant until seen by the healthcare provider. The fractured arm will be examined and x-rayed confirming the fracture.

Which client should the nurse assess first?

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first?

a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output The client with the elevated potassium level and poor renal elimination is the client to assess first as the condition could develop into cardiac concerns of arrhythmias such a ventricular fibrillation. Due to the seriousness of the complication, this assessment is the priority. Intense thirst and a low urine specific gravity (1.001- 1.003) is expected when diagnosed with diabetes insipidus. The blood glucose level of 175mg/dL (9.71 mmol/L) is elevated and insulin is given with morning breakfast. The blood glucose level is not at a critical level. The client with a serum calcium level of 8.2 mEq/dL (2.05 mmol/L) is low normal or slightly below normal (depending upon the source) and cramping may be an issue.

The nurse has received the change-of-shift report on the clients. Who should the nurse assess first?

a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered.

Which client should the nurse assess first?

a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

After administering prescribed medications to clients, which client requires immediate intervention?

a client taking digoxin who has a morning potassium level of 3.0 mEq/L The client's low potassium level increases the risk for digoxin toxicity and potential dysrhythmias. Digoxin inhibits the action of the sodium-potassium pump that moves sodium and potassium across the cell membrane and slows the electrical impulses through the atrioventricular node. This leads to a rapid reduction of the remainder of potassium ions available for the "pump" action, which can cause a buildup of toxic serum levels of digoxin. Digoxin toxicity can cause many types of cardiac dysrhythmias due to the increased intracellular calcium release and decreased AV conduction time slowing the heart rate. The nurse should notify the healthcare provider about the potassium level to prevent toxicity from occurring. The other clients are experiencing expected effects of the prescribed medication.

Multiple casualties have been brought to the emergency department after a bus accident. The triage nurse is determining who will need immediate care. Place the clients in order of priority. All options must be used.

a client with loss of consciousness and bleeding from the ears a client with severe lacerations involving open fractures of major bones a client with closed fractures of major bones a client with partial-thickness (second-degree) burns covering 10% of the body a client with pain from whiplash and soft-tissue injuries When planning triage of clients, loss of life and limb is prioritized along with the concepts of airway, breathing, circulation, and disability. A client with loss of consciousness and bleeding from the ears is at risk for a compromised airway and needs to be assessed for head trauma and would be seen first. The client with open fractures is at increased risk for hemorrhage (circulation) and would be seen next. The client with closed fractures is at risk for disability and would be seen next. The client with partial- thickness (second-degree) burns covering 10% of the body would be seen next to begin care of the burns and pain control. A client with partial-thickness (second-degree) burns to more than 10% of the body would be transferred to a burn center. The client with pain from whiplash and soft-tissue injuries is the most stable client and would be seen last.

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?

allergies In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease

Which factors are major components of a client's general background history?

allergies and socioeconomic status General background data consist of such components as age, allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy When assessing the past health history of a child, it is important to determine if the child has any medication and/or non-medication allergies, the reaction the child has to the allergen, as well as the severity of the allergy. Favorite foods and sibling history of allergies are not important to assess here.

For which client is the nursing assessment of pain most likely to result in undertreatment?

an older adult who grimaces and states no pain after a gastrostomy tube placement Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled.

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse?

auscultation of all four quadrants using a stethoscope The order of abdominal assessment includes observation, auscultation, percussion, and palpation. An assessment would be completed prior to reviewing the diagnostic report. The nurse would assess the client prior to administering pain medication.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below the client's cheekbones To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170 cm) female client who is 21 years of age?

brittle nails Brittle nails indicate poor nutrition. Poor posture indicates that the client does not stand up straight and use her muscles to support herself. A dull expression reflects the client's affect and emotional status. The client's weight of 128 lb (58.1 kg) is within normal range.

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

broth, gelatin cubes, and tea To begin the patient's transition to eating a regular diet, the nurse will first choose a clear-liquid diet. This includes transparent liquids, such as apple juice, ginger ale, and chicken broth. When clear liquids are tolerated, the client can then transition to a full-liquid diet consisting of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. Although milk, custard, and vanilla ice cream may be included in a bland diet, it may also include semi-solid and solid foods that are not spicy. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, and toast.

A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates what regarding a client's clinical status?

changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person This is the correct choice, as it offers specific measurable data about the client. The other choices are not complete neurologic assessments.

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?

clear, watery, yellow-tinged drainage Serous drainage is clear, watery plasma; sanguineous drainage is fresh, red bleeding; purulent drainage is thick and yellow; and purulent drainage with infection is beige to brown and foul smelling. White with sanguinous drainage and tenacious with yellow drainage are both indicative of an infection. Dark melena and foul smelling is indicative of a gastrointestinal bleed

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

An older adult reports being cold in the room even though the thermostat is set at 75°F (24°C). The nurse can tell the client that older adults may feel cold for which reason? Older adults have:

decreased ability to thermoregulate. Older clients have a decreased thermoregulation that is related to decreased blood supply and reabsorption of body fat. As a result, older adults are at risk for hypothermia. Cellular cohesion and moisture content diminish with age and cellular renewal time is slowed; however, these do not result in impaired thermoregulation.

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult?

decreased healing Normal aging consists of decreased proliferative capacity of the skin. Decreased collagen synthesis slows capillary growth, impairs phagocytosis among older clients, and results in slow healing. Increased scarring is not a result of age-related skin changes. Both melanin and melanocytes give color to the skin and hair but are increased with aging. There is a decrease in the immunocompetence of the aging client.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include

delayed gastric emptying. Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

The nurse is instructing an older adult about ways to promote skin integrity. Which health maintenance behavior by the client is most helpful?

drinks 1,500 mL of fluids per day Drinking at least 1,500 mL of fluid per day helps the client stay well hydrated. Maintaining optimal fluid balance is important for all body systems, and particularly the skin. Caloric intake varies according to an individual's size and activity level. An intake of 1,200 cal/day may be insufficient for some older clients. Walking 10 minute/day is useful, but an otherwise healthy older client should try to walk 20 to 30 minute/day three or more times a week. It is important to get adequate rest; however, the amount of sleep needed varies with the individual.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.

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?

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.

Which component of a client's medical record is the major source of subjective data about the client's health status?

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 assessing a client at the beginning of the shift. Which signs of hypoxia would alert the nurse to take further action?

increased pulse rate, oxygen saturation of 88%, and circumoral cyanosis This combination of symptoms indicates hypoxia. The other choices are incorrect and are not indicative of hypoxia.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?

ineffective breathing pattern The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?

intravenous fluid hydration Both the history and physical assessment support a client who is dehydrated. I.V. fluids would assist with rehydration and liquifying secretions. Although the pneumonia is important to treat aggressively, hydration is the priority.

The nurse is assessing the lower extremities of the client with peripheral artery disease (PVD). Which findings are expected? Select all that apply.

mottled skin coolness Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities

During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?

objective Physical examination techniques such as auscultation provide objective data, which reflect findings without interpretation. The client and client's family report subjective data to the nurse. The family and members of the healthcare team provide secondary source information. The nurse obtains medical data from the physician and medical record.

The most appropriate way for the nurse to assess a client's ability to perform activities of daily living is to:

observe client performing varied activities of daily living. In order to assess the client's ability to perform activities of daily living, it is important for nurses to observe clients actually performing them. This way, nurses can assess any problems occurring with a specific activity. Asking the client what he or she is able to do will not always provide reliable information, and documentation on the chart may not reflect if the client has had help in performing specific tasks. Family members can provide some information but are not trained in how to evaluate the client.

When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis?

oral mucous membranes In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment for determining cyanosis in any client.

When examining a client who has abdominal pain, a nurse should assess

the symptomatic quadrant last. The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

The nurse is monitoring a client who is receiving moderate sedation for a procedure. The client begins to display signs of restlessness and agitation. What assessment does the nurse perform first?

oxygen saturation When a client has received sedation, hypoxemia is a potential complication and should be suspected and assessed for immediately at the first signs of restlessness and agitation, as these can be early signs of hypoxemia. Hypoxemia can cause rapid decompensation and lead to respiratory or cardiopulmonary arrest if not rapidly identified and corrected. Fear and pain are also possible causes of restlessness and agitation, and should be assessed for, but not until after the nurse has ascertained that the client is not hypoxemic. The level of consciousness will be altered due to the moderate sedation and being too alert could be a sign of undersedation. This should be assessed but is not a priority over the oxygen level.

The nurse is reviewing the electronic health record of a newborn with pathologic jaundice receiving phototherapy. What factors put this newborn at risk for hyperbilirubinemia? Select all that apply.

prematurity Native American/First Nations ethnicity ABO incompatibility Breastfeeding and small for gestational age are not risk factors for pathologic jaundice. Prematurity, Native American/First Nations ethnicity, and ABO incompatibility are risk factors for pathologic jaundice.

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?

pulse deficit The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the difference between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

Which finding in a client who recently underwent a total hip replacement would require a nurse to take immediate action?

red painful area on the calf of the affected leg Deep vein thrombosis is a complication of total joint replacement and manifestations include a red tender calf. Ecchymosis around the incision site is a normal finding. The client's diaphoresis, fluid volume deficit, and edema in the nonaffected leg should be further assessed; however, the priority is the red tender calf.

When percussing a client's chest, what should the nurse expect to hear?

resonance Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest?

thrombophlebitis Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system

Which sign is an early indication that a client has developed hypocalcemia?

tingling in the fingers Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?

tripod position The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

A nurse compares a child's height and weight with standard growth charts and finds the child to be in the 50th percentile for height and in the 25th percentile for weight. How does the nurse interpret the child's growth pattern?

typical height and weight The values of height and weight percentiles are usually similar for an individual child. Measurements between the 5th and 95th percentiles are considered normal. Marked discrepancies identify overweight or underweight children.

The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about?

urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the health care provider. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

urine output of 90 mL over the past 6 hours Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.

A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would be evaluated as correct?

wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference When measuring blood pressure, the nurse either removes the client's clothing or moves it above where the cuff will the placed. The nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters of the limb circumference. The nurse chooses bladder size according to the size of the extremity. Using the automatic blood pressure cuff on all clients without cleaning would cause of spread of hospital-acquired infections.

What assessment findings in a 1-day-old neonate should the nurse expect when preparing to implement phototherapy? Select all that apply.

yellow skin yellow mucous membranes icteric sclera Physiologic jaundice is very common in newborns and usually occurs around the first three days of life. Phototherapy is warranted when the bilirubin level reaches 12 to 15 mg/dL (205 to 256 microcol/L) in the first 48 hours of life. Signs of jaundice include yellow skin, yellow or icteric eyes, and yellow mucous membranes. Weight gain is not a symptom expected in an infant with jaundice.