302 Final

While assessing a client's heart sounds, the nurse knows that S2 is caused by the closing of which valves? a) Aortic and pulmonic valves b) Pulmonic and mitral valves c) Aortic and tricuspid valves d) Mitral and tricuspid valves

a) Aortic and pulmonic valves

A client points to a sore on the leg and states, "I have an awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale brownish base, well defined edges, and no drainage. His lower extremity skin is thin and shiny. The nurse assessed and recognizes that these are objective data of which of the following conditions? a) Arterial insufficiency b) Venous insufficiency c) Lymphedema d) Varicose veins

a) Arterial inusfficiency

The nurse reads in an admission note that the physical examination of a client revealed an impairment of cranial nerve II. The nurse instructs ancillary caregivers to do which of the following when caring for this client? a) Clear the client's path of obstacles b) Serve food at room temperature c) Report difficulty swallowing d) Whisper to the client

a) Clear the client's path of obstacles. Rational: The optic nerve, which governs vision, is cranial nerve II. For this client it would be most helpful to clear the are of objects that may not be perceived by the client but that could lead to falls.

A scooped-out, shallow depression in the skin is called a(n) a) Erosion b) Ulcer c) Fissure d) Excoriation

a) Erosion. Rational: An ulcer is a deeper depression extending into the dermis. An excoriation is a self-inflicted abrasion that is superficial. A fissure is a narrow opening of tissue or skin. An erosion is a scooped-out, shallow depression in the skin.

The nurse is teaching a client to examine his testes as part of the annual physical examination. What should the expected findings of the testes feel like on examination? a) Firm, rubbery, and smooth. b) Firm to hard and rough. c) 2cm to 3cm long by 2cm wide and firm. d) Nodular

a) Firm, rubbery, and smooth. Rational: The client should examine the testicles at least once a year. The testes should not feel hard, should not have any lumps or bumps. It should be firm, rubbery for some, and smooth.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which EARLIEST sign of acute respiratory distress syndrome? a) Increased respiratory rate b) Intercostal retractions c) Inspiratory crackles d) Bilateral wheezing

a) Increased respiratory rate

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which EARLIEST sign of acute respiratory distress syndrome? a) Increased respiratory rate b) Intercostal retractions c) Inspiratory crackles d) Bilateral wheezing

a) Increased respiratory rate. Rational: The client is experiencing an episode of ACUTE respiratory distress. Even if the nurse does not know the condition, the body's physiological changes applies: increase RR. By the time the nurse notices intercostal retraction, hears crackles and wheezes, it;s late stage.

What is an assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged client? a) Measurable loss of height. b) The presence of bowed legs c) A dislike with dairy products d) Statements about frequent falls

a) Measurable loss of height. Rational: Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are not associated with osteoporosis. Low intake of dairy products is a risk factor for osteoporosis, but it is not an assessment finding that osteoporosis is present. Frequent falls increase the risk for fractures but again, not an assessment finding for osteoporosis.

When planning care for a client who is legally blind, the nurse should do which of the following as most important to ensure the client's safety? a) Orient client verbally and physically to the room b) Provide radio and TV for stimulation c) Leave doors partially closed d) Describe the weather and community events for clients

a) Orient client verbally and physically to the room. Rational: The nurse should orient the client to the room for safety, using both words and physical walking tour for the best effect.

Which gynecologic problem is NOT usually associated with intimate partner violence (IPV)? a) Ovarian cysts b) STIs c) Vaginal tearing d) Pelvic pain

a) Ovarian cysts. Rational: Patterns of IPV include psychologic abuse, sexual violence, and reproductive abuse. Ovarian cysts is not an associated factor with IPV.

The nurse assess a client and noticed irregular heart rhythm. The nurse decides to count for a full one minute. What is the nurse's concern in this case? a) Pulse deficit b) Increased pulse pressure c) Auscultatory gap d) Hypoxia

a) Pulse deficit

The nurse is demonstrating assessment of capillary refill of a client with a nursing student. The nurse notices the client's nail edge is slightly depressed, the capillary refill is about 4-5 seconds. Which response by the nurse to the nursing student reflects an accurate assessment? a) The client may have compromised cardiovascular or respiratory function b) Client has positive profile sign c) Client's nail bed color return is not indicative of anything significant d) A client's circulatory status is normal and unremarkable

a) The client may have compromised cardiovascular or respiratory function

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? a) The right eye is tested, followed by the left eye, and then both eyes are tested b) The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision. c) The client is asked to stand at a distance of 40 feet (12 meters) form the chart and to read the largest line on the chart. d) Both eyes are assessed together, followed by an assessment of the right eye and then the left eye.

a) The right eye is tested, followed by the left eye, and then both eyes are tested. Rational: Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measure with or without corrective lenses and the client stands at a distance of 20 feet (6 meters) from the chart.

A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a) Vitamin D is essential in helping the body absorb and use calcium b) Aerobic exercise is more advantages than weight-bearing exercises in preventing osteoporosis c) Daily dose of potassium helps to prevent osteoporosis d) Increase phosphorus metabolism may lead to bone fragility

a) Vitamin D is essential in helping the body absorb and use calcium. Rational: Calcium is important for skeletal muscle growth. Vitamin D through the skin, diet and supplement helps the body absorb and use calcium. While Vitamin D supplements can be taken with or without good and the full amount can be taken at one time, Vitamin D and calcium do not need to be taken together at the same time

What questions would the a nurse ask a client who has a history of a seizure. Select all that apply. a. Did you ever have convulsions? b. When did they start? c. How often do they occur? d. Any problem swallowing? a) a, b, c b) d, a, b c) c, d, a d) b, c, d

a) a, b, c Rational: Knowing the history will help the nurse to develop an individualized care plan for the client in addition to establish seizure precaution.

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan? Select all that apply. a. Maintaining an upright position while eating. b. Restricting the diet to liquids until swallowing improves. c. Introducing foods on the unaffected side of the mouth. d. Keeping distractions to a minimum. e. Cutting food into large pieces of finger food. a) a, c, d b) b, d, e c) a, c, d, e d) a, b, c, d

a) a, c, d Rational: A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side of the mouth will allow the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cur into bite-size.

When communicating with a client who has aphasia, which of the following are helpful? Select all that apply. a. Present one thought at a time. b. Avoid writing messages. c. Speak with normal volume. d. Make use of gestures. e. Encourage pointing to the needed object. a) a, c, d, e b) a, b, d c) a, b, d, e d) a, d, e

a) a, c, d, e Rational: The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

The nurse has provided instructions to a client with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. Which fluids should the nurse include in the client's teaching plan that will aid in acidifying the urine? Select all that apply. a. Milk b. Orange juice c. Cranberry juice d. Carbonated drinks a) b, c b) c, d c) a, b d) d, a

a) b, c Rational: Steps that may help to reduce the chance of getting UTIs include drinking plenty of water every day, cranberry juice, and large amount of vitamin Cs that limit the growth of some bacteria by acidifying the urine. Vitamin C supplements have the same effects.

A nurse is a performing a musculoskeletal examination on a client. Arrange the following steps in the order the nurse should perform them. All options must be used. a. Make the client comfortable for procedure. b. Use firm support, gentle movement, and gentle return to a relaxed state. c. Drape for full visualization of the body part without exposing the client. d. Take an orderly approach: head to toe, proximal to distal. e. Introduce self to client. a) e, a, c, d, b b) e, c, a, d, b c) a, b, d, c, e d) a, e, c, d, b

a) e, a, c, d, b Rational: This is an alternate format question that you may encounter in the NCLEX-RN exam and at least one in the final exam. Appearing first time in the weekly quiz for practice. Always start with AIDET - introduce self and explain procedure to ensure client is comfortable and ready to participate, then drape and prep the client for procedure. As the nurse moves through the procedure, the nurse ensure to make take an orderly approach form head to toe, proximal to distal, using firm support, gentle movement and return to a relaxed state to complete the assessment. This kind of question can be frustrating because the steps may not be complete. In this instance, you try to answer select the best flow possible. In the NCLEX world, one misstep, the entire question is wrong.

A client is being discharged from the hospital and will receive oxygen therapy at home. The nurse is teaching the client about oxygen safety measures. Which statement by the client indicates the need for further teaching? a) "I realize that I should check the oxygen level of the portable tank on a consistent basis" b) "It is alright to burn my scented candles as long as they are a few feed away from my oxygen tank" c) "I will not sit in front of my wood-burning fireplace with my oxygen on" d) "I will call the physician if I experience any shortness of breath"

b) "It is alright to burn my scented candles as long as they are a few feed away from my oxygen tank" Rational: It is NOT all right to use oxygen near a fireplace. This action requires additional teaching.

A nurse is assessing a client who has been diagnosed with a neuromuscular disorder. The nurse notes the client is struggling but slowly able to lift the right leg off the bed at 5 degree when the nurse is applying resistance. The nurse would document the muscle strength in the right leg as? a) 5/5 b) 3/5 c) 4/5 d) 2/5

b) 3/5 Rational: The client appears to show average weakness in this scenario. The rating appears to be 3/5 with the definition of active motion against gravity.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? a) to examine the testicles while lying down b) To gently feel the testicle with 1 finger to feel for a growth c) That TSE's should be done at least every 6 months d) After a shower

b) After a shower Rational: The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan? a) Use condoms whenever the partner seems "risky" b) Always apply the condom before inserting the penis into the vagina c) natural membrane condoms can be used because they are just as effective as latex d) condoms should not be lubricated

b) Always apply the condom before inserting the penis into the vagina. Rational: Male condoms are worn on the penis to prevent semen (sperm) entering the woman's vagina when the ejaculates (comes). The condom should be out on when the penis is erect (hard) and before it comes into contact with your partner's body.

A nurse is performing an examination on an unconscious client. The great toe extends upward, and the other toes fan out in response to stroking the lateral aspect of the sole of the foot. The nurse documents this as which of the following? a) Crushing response b) Babinski's sign c) Normal plantar relfex d) Hyporeflexia

b) Babinski's sign. Rational: Babinski's sign is defined as the extension (dorsiflexion) of the big toe and fanning of all toes in response to stroking the lateral aspect of the sole of the foot.

The nurse is performing client teaching in a clinic. Which food group is beneficial for the client to reduce the risk for colon cancer? a) Foods high in carbohydrates b) Foods high in fiber c) Foods high in protein d) Foods low in fat

b) Foods high in fiber. Rational: According to the American Institute for Cancer Research, plant-based foods rich in dietary fiber may reduce client's risk for colorectal cancer and help maintain a health weight, which is vital to reduce cancer risk.

The nurse is planning to assess a client's abdomen for rebound tenderness. How should this procedure be performed? a) Ask the client to assume a side lying position b) Palpate deeply while quickly releasing pressure c) Palpate lightly while slowly releasing pressure d) Perform the abdominal assessment first

b) Palpate deeply while quickly releasing pressure

A nurse is performing a wound assessment on a client sacral wound. On inspection, the nurse notes full thickness skin loss involving damage and necrosis of subcutaneous tissue that extends down to, but not through underlying fascia. The nurse determines the client has is which stage of pressure injury? a) Stage 1 b) Stage 3 c) Unstageable d) Stage 4

b) Stage 3 Rational: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed

The nurse is performing a cardiovascular assessment on a client. Which item should the nurse assess to obtain the best information about the client's left sided heart function? a) Presence of peripheral edema b) Status of breath sounds c) Presence of jugular vein distention d) Presence of hepatojugular reflux

b) Status of breath sounds

***The nurse is assessing the abdomen of a client and observes a purple discoloration at the flanks. The nurse understands the need to SBAR the physician for which of the following reasons? a) Suspect liver disease b) Suspect internal bleeding c) Suspect self injury d) Suspect abdominal distension

b) Suspect of internal bleeding

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? a) Test visual acuity, using a Snellen eye chart b) Test the 6 cardinal positions of gaze c) Test the corneal reflexes d) Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin

b) Test the 6 cardinal positions of gaze. Rational: Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes.

A nurse is developing a plan of care for an elderly client with a respiratory problem and formulates a nursing diagnosis of self-care deficit. The nurse develops which realistic outcome for the client? a) The client will be admitted to a nursing home to have ADL needs met b) The client will function at the highest level of independence possible. c) The client will complete all ADLs independently within a 1-1.5 hour time frame. d) The nursing staff will attend to all of the client's ADL needs during the hospital stay.

b) The client will function at the highest level of independence possible. Rational: Yes you want your client to be able to be independent and function at his or her own highest level. To have a time frame is not realistic at this point. You also do not want to help your client to do all the ADL as you want your client to eventually be independent.

A nurse is caring for a client newly diagnosed with rheumatoid arthritis. Which statement indicates the nurse understands the assessment about patient safety? a) The nurse instructs the client to get out of bed and take a cold shower in the morning b) The nurse helps the client to move slowly in bed when getting up in the morning c) The nurse instructs the client not to exercise once the disease is diagnosed d) The nurse helps the client to massage on the affected joint.

b) The nurse helps the client to move slowly in bed when getting up in the morning. Rational: A client with rheumatoid arthritis may experience morning stiffness and joint pain which last a good chunk of the day. To promote patient's safety and decrease fall risk is to help the client to get out of bed slowly. Helping to massage the affected joint is helpful in providing comfort but it does not provide safety. The rest of the options contradicts safety.

When a pre-surgical nurse inspects the interior of a mouth upon admission, what would the nurse expects to see? a) The tonsils are white b) The tongue is symmetric and has no lesions c) The tongue is symmetric and has a couple of white lesions d) The tonsils are uneven

b) The tongue is symmetric and has no lesions. Rational: This is the kind of question that you hope you do not encounter :what would the nurse expects to see. What does that suppose to mean anyway? In this case, it is asking you for an expected outcome aka normal outcome. You will respond with something 'normal'. The only correct answer is A.

When a child, elder, or vulnerable adult abuse, or neglect is disclosed, what should nurses do? a) Get family involved b) Understand this is a mandated report c) Consider a referral d) Contact the physician

b) Understand this is a mandated report Rational: The nurse must understand that they ARE mandated reporters when child, elder, vulnerable adult abuse or neglect is disclosed, assessed or suspected during an assessment.

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. What should the nurse do? a) Listen in each quadrant for 5 seconds b) Use the diaphragm of the stethoscope c) Palpate the abdomen before auscultation d) Begin auscultation in the left upper quadrant

b) Use the diaphragm of the stethoscope

A client with advanced chronic obstructive pulmonary disease (COPD) is very fatigued and on bed rest. The nurse understands the importance of clustering his care to provide comfort and safety. When is the MOST appropriate time for the nurse to auscultate the client's lungs? a) When ambulating the client b) When turning the client c) Immediately after the client's meal d) After bathing the client

b) When turning the client Rational: The client will be too tired when ambulating. lung auscultation will not be accurate. Immediately after a client's meal - digestion and movement will alter lung function, auscultation will not be accurate. After a bath, too much movement and activity, again, lung auscultation will not be accurate. Turning the client is movement but the action is minimal and not active, auscultation is likely more accurate.

The nurse is caring for an elderly hospitalized client who is malnourished. In conducting a comprehensive dietary assessment, what should be the method of choice for determining a client's dietary intake? a) 24 hour recall b) direct observation c) 3 day food diary d) food frequency questionnaire

b) direct observation

A nurse is teaching a client at a clinic how to perform skin assessment at home. Which of the following statements made by the client requires further teaching? a) "I will examine my skin for suspected lesions and report to the doctor." b) "I will always use a sunscreen of SPF 30 or higher when sun exposure is anticipated." c) "I will be fine with a few sunburns every now and then." d) "I will wear long -sleeved shirts and wide-brimmed hats."

c) " I will be fine with a few sunburns every now and then." Rational: It is best to reduce sun exposure, seek shade, and avoid any sunburn at all times. A few sunburns every now and then does not guarantee healthy understanding and willingness to learn.

The nurse is given discharge instructions to a client who was recently discharged from the hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is a need for further teaching if the client makes which statement? a) "I should cut my toenails straight across" b) "I should inspect my feet daily" c) "I should raise my legs above the level of my heart periodically" d) "I should wear my shoes and socks"

c) "I should raise my legs above the level of my heart periodically"

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? a) "I need to clean the eye as prescribed" b) "I need to wash my hands frequently" c) "It's ok to share towels and washcloths" d) "I need to give the eye drops as prescribed"

c) "It's ok to share towels and washcloths." Rational: The most common symptoms of bacterial conjunctivitis include red eye and discharge. The best approach is to avoid spreading the bacterial to others. Sharing of towels and washcloths are not practical as these will spread bacterial from one person to another.

The nurse notes that the absence of bowel sounds is established after listening for how long? a) 1 full minute b) 3 full minutes c) 5 full minutes d) 10 full minutes

c) 5 full minutes

Risk factors that may lead to skin disease and breakdown include: a) Decreased vascular fragility b) Increased thickness of the skin c) A lifetime of environmental trauma d) Loss of protective cushioning of the dermal skin layer

c) A lifetime of environmental trauma. Rational: Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

A client who has had seizure asks the nurse about being able to drive because of seizures. Which response by the nurse is best? a) A person with history of seizures can drive only during daytime hours. b) A person with a history of seizures can drive if he or she carries a medical identification card. c) A person with evidence that the seizures are under medical control can drive. d) A person with evidence that seizures occur no more than often than every 12 months can drive.

c) A person with evidence that the seizures are under medical control can drive. Rational: Specific motor vehicle regulations and restrictions for people who experiences seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of the day is not consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency.

A client has a BMI of 14. Which of the nursing interventions should the nurse perform for this client? a) Reduce total fat and calorie intake b) Increase intake of green leafy vegetables c) Provide additional high protein and calorie shakes d) Eat complete meals twice a day

c) Provide additional high protein and caloric shakes

The nurse is assigned a group of clients during shift. Which of the following clients are at greatest risk for malnutrition and requires a nursing student to assist in feeding? a) A client who is nothing by mouth for a scheduled surgical procedure b) A client who requires 2 person assist with ADLs c) A person with poor dentition d) A client who is on a prescribed 2 hourly tube feeding

c) A person with poor dentition

Which of the following describes decerebrate posturing? a) Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b) Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet c) Back arched, rigid extension of all four extremities d) Supination of arms, dorsiflexion of the feet

c) Back arched, rigid extension of all four extremities. Rational: Decerebrate position occurs in clients with damage upper brain stem, midbrain or pons and its demonstrated clinically by arching of the back, ridged extension of the extremities, pronation of the arms and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrist, and fingers descries decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

The nurse is admitting a client from the emergency department following a fall that resulted in increased intracranial pressure (ICP). The nurse interprets that the client's Glasgow Coma Scale score has improved the most after making which of the following latest assessments? a) Best eye-opening response 5, best motor response 4, best verbal response 8 b) Best eye-opening response 3, best motor response 8, best verbal response 6. c) Best eye-opening response 4, best motor response 6, best verbal response 5. d) Best eye-opening response 6, best motor response 5, best verbal response 4.

c) Best eye-opening response 4, best motor response 6, best verbal response 5. Rational: The Glasgow Coma Scale is divided into three subsets. Each subset has a range of scores within it, and for the total scale the highest possible score is 15 while the lowest is 3.

The nursing student is asked to document the stool collected on a client in the electronic health record. Which documentation indicates the nursing student understands how to describe normal stools? a) Black in color and tarry in consistency. b) Brown in color and loose in consistency c) Brown in color and soft in consistency. d) Clay-colored and dry in consistency

c) Brown in color and soft in consistency. Rational: Normal stool should look brown and soft in consistency. Any of the above would be abnormal in nature and should warrant further investigation.

The client hurt the right knee while playing soccer. The right knee appeared swollen. What would be the nurse's first assessment? a) Palpate for crepitus the knee b) Feel the knee for warmth c) Compare the swollen knee to the other knee d) Assess active ROM in the knee

c) Compare the swollen knee to the other knee. Rational: The nurse should first compare both knee to confirm the swell. The nurse then checks to feel for warm and assess for pain. Palpate for crepitus and assessing active ROM should not be a priority until clearance is checked and given.

The client states "my arm is hot and red" the nursing student understands to use which part of the hands to assess skin temperature a) Palmar surface of the hand b) Ventral surface of the hand c) Dorsal surface of the hands d) Fingertips

c) Dorsal surface of the hands

Which of the following assessment tasks can you appropriately delegate to unlicensed assistive personnel (UAP)? An UAP is defined as an individual who function in a supportive role by providing client care activities delegated by the RN. The term includes, but not limited to nurse aids, assistants, PCTs, CNAs, MAs. a) Active and passive ROM b) History of current complaint c) Height, weight, and vital signs d) Muscle strength

c) Height, weight, and vital signs Rational: You will often encounter these kinds of delegation NCLEX-RN questions, in a much more complex scenario. You will need to return to the WAC to understand the role of the RN, PCTs, CNAs, etc to know what can and cannot be delegated. In health interview and physical examination , including patient teaching, we mentioned in week 1, these skills cannot and should not be delegated.

A nurse examines a client with paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation? a) Normal bowel sounds b) Hyperactive bowel sounds c) Hypoactive bowel sounds d) Present bowel sounds

c) Hypoactive bowel sounds

A nurse is teaching a client breast self-examination in an outpatient setting, which of the following teaching is MOST accurate? a) Pregnant or breast-feeding woman may choose not to examine their breasts b) Everyone should practice breast self-examination c) It is best to examine the breast when it is not tender or swollen d) Any new changes to the breast indicate cancer

c) It is best to examine the breast when it is not tender or swollen. Rational: New changes to the breast do not always indicate cancer. It is acceptable for male and female to choose not to practice breast self-examination, but they are encouraged to become familiar with the normal look and feel of their breasts and report any changes to their health care provider immediately. Pregnant and breast-feeding women may choose to examine their breasts. The correct response is to best examine the breast when it is not tender or swollen - comfort.

The nurse recognizes that a few lymph nodes in the neck of a client who indicates a pharyngitis. What may be some characteristics of these nodes? a) Matted, fixed, tender, hard b) Matted, fixed, nontender c) Palpate, tender, warm d) Large, clumped, tender

c) Palpable, tender, warm Rational: Usually lymph nodes are not palpable in an adult clients, but some times a few lymph nodes can be palpable in an otherwise health clients, and may mean nothing. If so, it will feel mobile, soft and non-tender. In this case when a client indicates a sore throat, the lymph nodes are usually palpable, warm to touch and tender. It will not feel matte, hard, rubbery, irregular, fixed and nontender. That would very likely be signs of lymphoma.

The nurse performs an initial baseline assessment on a client on admission and notices the client's pulses are irregular. Which action should the nurse take next? a) Palpate the radial pulse on the other side of the arm b) Use the doppler machine to the radial pulse c) Palpate the radial pulse for a full minute. d) Document the finding and recheck 15 minutes later

c) Palpate the radial pulse for a full minute. Rational: The nurse will first palpate the radial pulse for a full minute to obtain an accurate reading. After which, the nurse may re-check on the other arm, or use a doppler machine. If the readings are abnormal, the nurse will document, make the clinical decision whether to inform or re-check.

A client presents to the clinic with silvery plaques on both elbows that are not itchy, but bleed when the scales are removed. The nurse concludes that the client most likely has which of the following conditions? a) Eczema b) Poison ivy c) Psoriasis d) Contact dermatitis

c) Psoriasis. Rational: Psoriasis is characterized by the presence of silvery plaques, particularly on the extensor prominences that bleed when scales are removed.

The triage nurse at the Fast Track Clinic admitted a patient for a head cold and cough. How should the nurse document expected findings of the external ears in the patient's electronic health record? a) Erythema and warm at right earlobe, but no lumps or bumps b) Erythema, tender to touch, and warm at right earlobe, but no lumps or bumps c) Skin intact, clean and dry. No lumps or bumps

c) Skin intact, clean and dry. No lumps or bumps. Rational: An expected finding documentation should read skin intact, clean and dry, If it is red (erythema) and warm to touch, there are lumps and bumps, those are signs of concerns.

The nurse notices a nursing student is preparing to take a blood pressure measurement on a frail elderly client using a large sized cuff. What should the nurse expect the reading to look like? a) The reading will be difficult to obtain due to age. b) The reading will be accurate as long as 2-step BP method is used c) The reading will yield a falsely low blood pressure d) The reading will yield a falsely high blood pressure

c) The reading will yield a falsely low blood pressure. Rational: When the cuff is too large, it will always yield a falsely low reading. A cuff that is too small will yield a measurement that is higher.

During the comprehensive health history interview, the nurse asks questions about the client's past health history. What is the primary purpose of asking about past health history in a comprehensive health history interview? a) To determine whether genetic conditions are present b) To summarize the family's health problems c) To evaluate how the client's current symptoms affect the client's lifestyle. d) To identify risk factors to the client and the client's significant others

c) To evaluate how the client's current symptoms affect the client's lifestyle. Rational: The purpose of asking a client's past health history is to evaluate how his or her past history ties in with current illness and lifestyle

The client is participating in a prostate screening clinic for men. Which subjective complaints by a client are associated with a benign prostatic hypertrophy? a) Painful urination b) Foul-smelling urine c) trouble starting a urine stream d) normal force in urinary stream

c) Trouble starting a urine stream. Rational: With BPH, the prostate gets larger and it irritates or block the bladder. Hence the client will verbalize weak urine flow, difficulty starting a urine stream or dribbling, need to push or strain to urinate.

A nurse is evaluating a client newly diagnosed with hypertension about understanding dietary modifications to control disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections? a) Hot dog on a bun, sauerkraut, baked potato b) Scallops, French fries, salad with bleu cheese dressing c) Turkey, baked potato, salad with oil and vinegar d) Corned beef, fresh carrots, boiled potatoes

c) Turkey, baked potato, salad with oil and vinegar

The nurse is performing an oral assessment of a client prior to feeding. The nurse proceeds to feed when which of the following findings are expected in an oral assessment? Select all that apply. a. Oral mucosa is light pink and moist, with no exudate. b. Tonsils are present and not inflamed or enlarged. c. Pharynx is smooth, moist, and pink. d. The tongue has two small white lesion on the side. a) d, a, b b) b, c, d c) a, b, c d) c, d, a

c) a, b, c Rational: The nurse should always obtain an oral baseline assessment of the client prior to feeding. This is one of the safety checks. Also, prior to and after feeding it is good practice for the nurse do regularly inspect the client mouth to ensure the oral mucosa is clean, pink and moist with no exudate, tonsil, if present, is not inflamed, there is good dentition, if dentures are not used. Pharynx is moist, no sore throat. The tongue is clean and no white lesions noted. Oral hygiene must be practiced at all times.

A nurse is caring for a client newly diagnosed with osteoporosis. Which statements should the nurse include when teaching the client about the disease? Select all that apply: a. Osteoporosis is common in females. b. Osteoporosis is a degenerative disease characterized by a decrease in bone density. c. The disease is congenital, caused by poor dietary intake of milk products. d. Osteoporosis can cause pain and injury. e. Passive ROM exercises can promote bone growth. f. Weight-bearing exercise should be avoided. a) b, d, e b) a, d, f c) a, b, d d) b, c, e

c) a, b, d. Rational: Osteoporosis is a degenerative metabolic bone disorder in which the rate of bone resorption accelerates, and the rate of bone formation decelerates, thus decreasing bone density. The decrease in bone density can cause pain and injury. Osteoporosis is not a congenital disorder; however, low calcium intake does contribute to it. Passive ROM exercises may be performed, but they will not promote bone growth. The client should be encouraged to participate in weight-bearing exercise because it promotes bone growth.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? a) Exposed bone, tendon, or muscle b) Full-thickness skin loss c) Partial-thickness skin loss of the dermis d) Intact skin

c) partial-thickness skin loss of the dermis. Rational: Stage II pressure injury, the skin is not intact. Partial thickness skin loss of the dermis has occurred. It presents as shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister.

The nurse is interviewing a client who has heart failure about his symptoms. Which of the following questions correctly inquires about orthopnea? a) "How many blocks can you walk before you feel short of breath?" b) "Does the cramping in your legs improve when you stop and rest?" c) "Is the swelling in one or both legs?" d) "How many pillows do you use under your head when you sleep?

d) "How many pillows do you use under your head when you sleep?"

A client reports that a previous right hip replacement is suddenly painful. Which hip assessment technique should the nurse omit? a) Extension b) Circumduction c) Hyperextension d) Adduction

d) Adduction Rational: The nurse should omit adduction as the client has a hip replacement surgery performed previously. The nurse has to further assess for signs for dislocation.

A nurse is conducting a comprehensive nutritional assessment on a client with suspected malnutrition. Why should it be important for the nurse to assess the client's ability to cook? a) Understand whether the client wants to learn how to cook b) Evaluate the client's food preference c) Determine if the client is interested in shopping for grocery d) Assess if the client can obtain or prepare food

d) Assess if the client can obtain or prepare food

The nurse is teaching a group of youth in the school about skin cancer. What does the "A" in the ABCDE rule for melanoma skin cancer stands for? a) Approximated b) Accuracy c) Appearance d) Asymmetry

d) Asymmetry. Rational: The A stands for Asymmetry. B- border, C- color, D- diameter, E- evolving

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? a) Lie still and watch the television b) Increase sodium in the diet c) Increase the fluid intake to 3000 mL a day d) Avoid sudden head movements

d) Avoid sudden head movements. Rational: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Think safety first.

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glassgow Coma Scale the nurse notes that the client opens the eyes only as a response to pain, responds to sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do NEXT? a) Attempt to arouse the client b) Reposition the client with the extremities in normal alignment c) Notify the physician d) Chart the client's level of consciousness as coma

d) Chart the client's level of consciousness as coma. Rational: The client has a score of 6 (eye opening to pain=2; verbal response, incomprehensible sounds =2; best motor response, abnormal extension =2). A score less than 7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of lim extension. It is not necessary to notify the physician as this assessment does not represent a significant change in neurological statues.

The nurse is caring a for a hearing-impaired client. Which approach will facilitate communication? a) Speak loudly b) Speak directly into the impaired ear c) Speak frequently d) Face the client when speaking.

d) Face the client when speaking. Rational: The nurse should face the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Think communication skills and delivery. The nurse should also have a bright light behind so the individual can see, and not block out the person's view of the speaker's mouth.

A client with pneumonia has a temperature of 1030 F, RR 24 breaths/min, PR 68 beats/min. The nurse confirms the client has ineffective airway clearance related to thick sputum as evidenced by rapid respiration, diminished and adventitious lung sounds heard in right lower lung field. What nursing intervention would be MOST appropriate? a) Position to decrease workload of breathing b) Administer oxygen c) Elevate head of bed d) Increase fluids

d) Increase fluids Rational: Ineffective airway clearance due to thick sputum, you want to increase fluid to loosen the secretion. Thus allow the client to cough out. The rest of the intervention will not be effective in relieving airway clearance but may help with gas exchange.

A community health nurse is providing an educational session on cancer of the cervix for women living in the community. The nurse informs the community residents that which is an early sign of this type of cancer? a) abdominal pain b) dark and foul-smelling vaginal drainage c) constant and profuse bleeding d) irregular vaginal bleeding or spotting

d) Irregular vaginal bleeding or spotting Rational: Early cancer of the cervix usually is asymptomatic. The 2 chief symptoms are leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge increases gradually in amount and becomes watery and finally dark and foul-smelling because of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may become constant and may increase in amount.

When doing an assessment of the spine of an older client, the nurse can expect to see which variation? a) Lordosis b) Scoliosis c) Torticollis d) Kyphosis

d) Kyphosis Rational: Kyphosis is the excessive outward curvature of the spine, causing hunching of the back and most commonly seen in older woman and often relates to osteoporosis.

A client explains that she is aware of her own heartbeat. The nurse understands this and documents this findings as a) Heaves b) Chest pain d) Thrill d) Palpitations

d) Palpitations

A client in a nursing home is admitted with a diagnosis of dementia. The client started a fire while cooking at home and forgot that there was a pan on the stove. Which is the nursing diagnosis that has the highest priority? a) Impaired memory b) Acute confusion c) Ineffective brain tissue perfusion d) Risk for injury

d) Risk for injury. Rational: All of the nursing diagnoses are appropriate for the client with dementia. In this case, risk for injury is the highest priority because patient's safety is the top priority.

Which of the following is included in the Braden Scale a) Bedrest, moisture, nutrition, elimination, friction and shear. b) Comfort, nutrition, care, risk potential, screening, elimination. c) Sensory perception, mobility, visibility, fall risk, vision, balance, support, elimination d) Sensory perception, moisture, activity, mobility, nutrition, friction, and shear.

d) Sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Rational: There are six categories within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

29. What percussion sound is heard over most of the abdomen a) Hyperresonance b) Flat c) Resonance d) Tympany

d) Tympany

The nurse is conducting a general survey of a patient on admission to the floor. In what part of the survey would the nurse assess the hair distribution on the patient's body? a) When assessing the behavior b) When assessing the posture c) When assessing the mobility d) When assessing the skin

d) When assessing the skin Rational: When assessing the skin can you assess hair distribution. The rest of the general survey is not appropriate.

The nurse is caring for a client with Stage IV pressure injury. During the dressing change the nurse notes which of the following characteristics? Select all the apply. a. Erythema. b. Subcutaneous tissue. c. Bone. d. Muscle. e. Dermis. a) b, c b) d, e c) a, b d) c, d

d) c, d Rational: Skin breakdown occurs when the skin is compressed against a bony surface and blood flow to the area is restricted. In State I the skin is intact but reddened without blanching. In State II, skin is lost from the dermis or epidermis. An abrasion, blister, or shallow crater may be present. There is a full thickness skin loss in Stage III, but it does not extend through the fascia. There is either a deep crate or eschar forms over the area of breakdown. Breakdown may extend under the skin and beyond the margins of the wound. In Stage IV, there is extensive breakdown that extends into the muscle and bone. There are usually areas of breakdown that extend under the skin and beyond the margins of the wound. Necrosis is often present.

The nurse is preparing to interview a client for the first time. The nurse observes that the client appears very anxious. Which of the following action is MOST appropriate for the nurse to do at this time? a) continue with the interview b) avoid discussing sensitive issues c) set time limits with the client d) explain the role and purpose of the interview

d) explain the role and purpose of the interview Rational: You want to reassure your client to so as to seek cooperation and to calm the situation. The rest of the actions do not show respect or simply show the nurse is ignoring the situation.