ADN140 - Exam two

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention

A

A newly hired occupational health nurse at an industrial facility is performing an initial workplace assessment. Which of the following information should the nurse determine when conducting a work site survey? A. Work practices of employees B. Past exposure to specific agents C. Past jobs of individual employees D. Length of time working in current role

A

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

A

A nurse is conducting a community assessment. Which of the following data collection methods is the nurse using when having direct conversations with individual members of the community? A. Key informant interviews B. Participant observation C. Focus groups D. Health surveys

A

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5minutes before you measure their blood pressure."

A

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.

A

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A, B

A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply.) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test

A, B

A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

A, B, C

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30sec if it is irregular. E. Count and report any sighs the client demonstrates.

A, B, C

A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression

A, B, C, D

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) A. Explain the roles of other care delivery staff. B. Begin discharge planning. C. Inform the client that advance directives are required for hospital admission. D. Document the client's wishes about organ donation. E. Introduce the client to their roommate.

A, B, D, E

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply.) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing."

A, C, D, E

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

A, C, E

A nurse is preparing to conduct a windshield survey. Which of the following data should the nurse collect as a component of this assessment? (Select all that apply.) A. Ethnicity of community members B. Individuals who hold power within the community C. Natural community boundaries D. Prevalence of disease E. Presence of public protection

A, C, E

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous macules on the face darker than the surrounding skin color

A, D, E

A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

A, D, E

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline

A, D, E

A nurse is caring for a client who is from a different culture than the nurse. When beginning the cultural assessment, which of the following actions should the nurse take first? A. Determine the client's perception of their current health status. B. Gather data about the client's cultural beliefs. C. Determine how the client's culture can affect the effectiveness of nursing actions. D. Gather information about previous client interactions with the health care system.

B

A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

B

A nurse is completing a needs assessment and beginning analysis of data. Which of the following actions should the nurse take first? A. Determine health patterns within collected data. B. Compile collected data into a database. C. Ensure data collection is complete. D. Identify health needs of the local community.

B

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client's blood pressure.

B

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

B

A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling

B, C, D

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.

B, C, D, E

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (Select all that apply.) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature

B, C, E

A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.

B, C, E

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur

B, D

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.

B, D, E

A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

C

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

C

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C

A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following activities? A. Exercising the deltoid muscle when using hand weights B. Brushing the hair on the back of the head C. Fastening or zipping closures on the back while dressing D. Reaching into a cabinet above the sink

C

A nurse is completing an ecomap as part of a family assessment. Which of the following questions should the nurse plan to ask to gather appropriate data? A. "Do you have a family history of heart disease?" B. "What kinds of foods does your family eat?" C. "Is your family involved in any community organizations?" D. "How does your family cultural beliefs influence your health values?"

C

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C, D, E

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C, D, E

A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

C, E

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

C, E

A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

D

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.

D

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing

D

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella

D, E