exam 1 nur 102

cheyne-strokes

this conditions is caused by congestive heart failure, drug overdoes, increased intracranial pressure, impending death

arterial catheter

this is a direct method for measuring a client's blood pressure

800 cells/mm3

A nurse is reviewing a client's complete white blood cell (WBC) count and differential. The nurse determines that the client is experiencing neutropenia based on which absolute neutrophil count? -1,800 cells/mm3 -1,100 cells/mm3 -800 cells/mm3 -1,500 cells/mm3

Pain rating is 7

The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data? -Bilateral pedal edema 2+ -Pupils equal and accommodate and react to light -Wheezing throughout lung fields -Pain rating is 7

an inference

The nurse is reviewing information about a client and notes the following documentation: "Client is confused." The nurse recognizes this information is an example of: -primary data. -a data cue. -subjective data. -an inference.

indwelling urinary catheter

The nurse is reviewing prescribed orders for a client. Which has the highest risk of infection? -soap suds enema -indwelling urinary catheter -subcutaneous injection -oral hygiene with suctioning

A= Assessment

The nurse is speaking to the physician regarding the client's frequent diarrhea episode since starting IV antibiotics. The nurse states "I am concerned that Mr. Clark has developed Clostridium Difficile infection". Which part of the SBAR communication will this statement fall into? -S= Situation -B= Background -A= Assessment -R= Recommendation

Termination phase

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? -Preparatory phase -Working phase -Termination phase -Introductory phase

"Picture yourself with good posture standing; that is how good lying posture works."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? -"Your feet should be at 45-degree angles from the legs." -"Keep knees and legs very straight." -"Picture yourself with good posture standing; that is how good lying posture works." -"Sleep with your head tilted to one side to take pressure off your neck."

turns arms downward, and then upward

The nurse is teaching a client about moving joints into positions of pronation and supination. Which client action reflects that teaching has been effective? -tilts chin down to touch chest, then stretches head back comfortably far -moves legs away from the midline, then toward the midline -turns arms downward, and then upward -turns sole of foot toward the midline, then away from the midline

Stand within the walker

The nurse is teaching a client who has been on prolonged bed rest about using a walker. Which teaching will the nurse include? -Stand within the walker. -Grip the walker by the front bar. -Pick up the walker and advance it 10 to 12 inches. -Move the walker in tandem with taking a step forward.

The new nurse touches 1.5 in (4 cm) from the outer edges

The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required? -The top flap of the package is opened away from the new nurse's body. -The new nurse touches 1.5 in (4 cm) from the outer edges. -Direct visualization of the sterile field is maintained. -The sterile field is set up at waist level.

Note the client's ability to swallow

When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention? -Ask the client to shrug his shoulders against resistance. -Assess the client's pupillary reaction to light. -Note the client's ability to swallow. -Test the client's nostrils for smell reception.

Pathogenic

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumonia, which is particularly prone to cause infections, also referred to as what? -Specific -Virulent -Source -Pathogenic

Pulmonary embolism

A 45-year-old woman is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20-year history of smoking. She also takes oral estrogen to manage her hot flashes. As a nurse assesses the client, she notices that the client's left leg is dark purple and measures 2 inches (5 cm) larger than her right leg. What is the client most at risk for? -Pressure ulcer -Arterial insufficiency -Surgical wound infection -Pulmonary embolism

"Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach."

A 59-year old female client reports to the nurse that she recently began taking alendronate and has been having stomach cramping, nausea, and diarrhea. How will the nurse educate the client? -"Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach." -"Discontinue taking the medication immediately." -"Take this medication monthly instead of weekly." -"These side effects are normal, so do not worry about them."

placing a small towel under the neck

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? -positioning the client on the stomach -placing a small towel under the neck -contacting the primary care physician -administering a muscle relaxer

cyst

A ____ is an encapsulated, round, fluid-filled

wheal

A _____ is an elevated mass with an irregular border and no free fluid

generation of a fever response

A nurse is reviewing laboratory test results and finds that a client's neutrophil levels are elevated. The nurse understands that these cells are important for: -disposal of cellular debris. -synthesis of immunoglobulins. -generation of a fever response. -antigen-antibody response.

3.2 mmol/L

A nurse is reviewing the laboratory test results of a client who is at high risk for septic shock. Which serum lactate level would the nurse identify as indicating sepsis? -1.4 mmol/L -0.8 mmol/L -3.2 mmol/L -2.6 mmol/L

Loss of appetite

A nurse is reviewing the medical record of a client with a systemic infection. What would the nurse expect to find? -Warmth -Erythema -Edema -Loss of appetite

the client has developed a bacterial infection

A nurse is reviewing the white blood cell (WBC) count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating: -the client is experiencing a subclinical infection. -the client's body is overcoming the infection. -the client most likely has a virus causing the shift. -the client has developed a bacterial infection.

Rectal

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used? -Forehead -Oral -Axillary -Rectal

Examine testicles for lumps monthly while showering

A nurse is teaching a client about testicular self-examination. What should be included in the teaching? -Check the testes weekly for lumps while laying down in bed. -Visualize the testes in the mirror looking for lumps monthly. -Examine testicles for lumps monthly while showering. -Squeeze each testicle gently feeling for lumps twice a month.

Exercise increases intestinal tone, Exercise increases efficiency of the metabolic system, Exercise increases blood flow to kidneys

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. -Exercise increases resting heart rate and blood pressure. -Exercise increases blood flow to kidneys. -Exercise decreases rate of carbon dioxide excretion. -Exercise increases intestinal tone. -Exercise increases efficiency of the metabolic system. -Exercise decreases appetite.

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age does she need to begin having mammograms. What is the nurse's best response? -"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." -"Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." -"Your physician will decide when it is best for you to begin having mammograms based on your family history." -"Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

Reflexes

A nurse is testing the function of the spinal cord of a client who presents in the emergency department following a motorcycle accident. What would be the focus of this assessment? -Reflexes -Motor ability -Sensory abilities -Balance and gait

Senses of vision, hearing, smell

A nurse is using inspection as an assessment technique. What does the nurse use during inspection? -Equipment such as a stethoscope -Both hands to produce sounds -Senses of vision, hearing, smell -Light palpation to detect surfaces

Perform hand hygiene before and after entering the client's room

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse also has another client today who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection? -Avoid direct contact with the client. -Wear gloves when touching the client. -Wear a mask and gown in the client's room. -Perform hand hygiene before and after entering the client's room.

Hepatitis B, Hepatitis C, HIV

A nurse is working with a new graduate nurse. The nurse states that she was exposed to a client's blood and that she was not wearing any PPE. Which would be considered significant blood exposures by occupational health? Select all that apply. -Hepatitis C -Tuberculosis -HIV -Hepatitis B

Virus

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? -Virus -Bacteria -Parasites -Fungi

pediculosis

Infestation with lice

Palpation

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? -Inspection -Percussion -Palpation -Auscultation

Skin warm and flushed

The nurse is assessing a client with an elevated temperature. Which of the following would lead the nurse to determine that the client is in the fever phase? -Reduced shivering -Profuse diaphoresis -Evidence of gooseflesh -Skin warm and flushed

Note the client's ability to swallow

When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention? -Note the client's ability to swallow. -Assess the client's pupillary reaction to light. -Test the client's nostrils for smell reception. -Ask the client to shrug his shoulders against resistance.

Use a rigid splinting material

The telehealth nurse is speaking with a parent whose child jumped off a couch and now is crying and holding the forearm. Which teaching will the nurse provide regarding emergency splinting? -Tie the splint securely so that fingers swell gently. -Use a rigid splinting material. -Place the splinted arm lower than the heart. -Secure the splint with adhesive tape.

Toes are dry and cool to touch

The urgent care nurse is assessing a client who had a plaster cast applied to the left ankle 4 hours ago. The client has come back to the urgent care with concerns. Which finding requires immediate nursing intervention? -Toes are dry and cool to touch. -Shape of cast has changed slightly. -Capillary refill is 3 seconds. -Client reports pain of "4" on 1-10 scale.

ability to identify fine touch

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment? -ability to sense vibrations -ability to identify fine touch -ability to identify sharp and dull touch -ability to differentiate temperature change

It reduces sound from air turbulence and prevents hyperventilation

When assessing the sounds of a client's lungs, the nurse asks the client to breathe in and out through an open mouth, deeply but slowly. How does this intervention help in the assessment? -It ensures that characteristics during each phase of ventilation is heard. -It helps to clear the air passages and open the alveoli. -It facilitates hearing sounds in the upper and lower lobes. -It reduces sound from air turbulence and prevents hyperventilation.

It reduces sound from air turbulence and prevents hyperventilation

When assessing the sounds of a client's lungs, the nurse asks the client to breathe in and out through an open mouth, deeply but slowly. How does this intervention help in the assessment? -It reduces sound from air turbulence and prevents hyperventilation. -It facilitates hearing sounds in the upper and lower lobes. -It helps to clear the air passages and open the alveoli. -It ensures that characteristics during each phase of ventilation is heard.

pallor, weakness, or dizziness

When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for? -walking gait -pallor, weakness, or dizziness -upper-arm strength -tone and strength of the muscles

women

When dealing with men and women, who usually has a greater variations in their temperature

use the client's own words placed in quotation mark

When documenting subjective data, the nurse should: -paraphrase the information stated by the client. -validate the information with the client's family prior to documentation. -use the client's own words placed in quotation marks. -record the information using nonspecific words.

tissue injury, dilation of blood vessels, plasma flow out of capillaries, white blood cell migration to the area, phagocytosis

When explaining the inflammatory response to nursing students, the instructor describes a series of events. Place the events in the order in which the instructor would describe them

if sounds occur after a long interval

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive

mass, tone, strength

A nurse is assessing the muscles of an older adult. What will be assessed? -reflexes, range of motion -mass, tone, strength -degree of flexion, associated pain -temperature, turgor, moisture

when hands are not visibly soiled

When is hand hygiene with an alcohol-based rub appropriate, as opposed to using handwashing? -when hands have been in contact with blood or body fluids -when hands have been in contact with blood or body fluids, but there is no visible soiling -when hands are not visibly soiled -before eating and after using the restroom

Inspection, auscultation, percussion, palpation

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order? -Inspection, auscultation, percussion, palpation -Palpation, percussion, inspection, auscultation -Percussion, auscultation, inspection, palpation -Inspection, percussion, auscultation, palpation

Toddler

When performing an assessment, the nurse should focus on the developmental stage for which client? -Adolescent -Middle-age adult -Toddler -Young adult

rectus femoris, vastus intermedius, vastus medialis, vastus lateralis

When preparing to teach a client about quadriceps setting, the nurse recognizes that which muscles will be involved? (Select all that apply.) -gluteus minimum -vastus lateralis -gluteus maximus -gluteus medius -vastus intermedius -rectus femoris -vastus medialis

white blood cell count of 14,000/mL

When providing pin care for a client who has an external fixator, which assessment finding requires the nurse to intervene? -client uses patient-controlled analgesia (PCA) pump -crusted secretions are present around pins -serosanguineous draining is noted -white blood cell count of 14,000/mL

removes gloves and walks out of the room

The nurse observes an unlicensed assistive personal (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene? -asks the client to state name and date of birth -removes gloves and walks out of the room -applies a mask with face shield -performs hand hygiene before donning gloves

Orthopnea

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as: -Apnea -Tachypnea -Bradypnea -Orthopnea

National Institute for Occupational Safety and Health (NIOSH)

The nurse recognizes that which organization requires that employers comply with ergonomic recommendations? -American Nurses Association (ANA) -The Joint Commission (TJC) -National Institute for Occupational Safety and Health (NIOSH) -National League for Nursing (NLN)

a client's heart murmur

The nurse should use the bell of the stethoscope during auscultation of: -a client's bowel sounds. -a client's heart murmur. -a client's breath sounds. -a client's apical heart rate.

Redness, Swelling, Pain, Exudate

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply. -Swelling -Exudate -Redness -Coolness -Pain

"Pieces of moleskin that cover rough edges of the cast."

The nurse tells a newly casted client that "petals" will be applied. What is the appropriate nursing response when the client asks, "what are petals?" -"Porous material from which the cast is made." -"A type of plaster that reinforces the strength of the cast." -"Pieces of moleskin that cover rough edges of the cast." -"Large bandages that surround the cast to keep it in place."

Focused assessment

An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? -Time-lapse assessment - Initial assessment -Focused assessment -Emergency assessment

Candida

is an element of normal human flora and has the ability to live on many environmental surfaces

Alopecia

is baldness and seborrheic dermatitis causes scaly, greasy patches to form on the head.

ataxis

is impaired muscle coordination

Kyphosis

is increased convexity in the thoracic spine from disk shrinkage and decreased height, common in older adults

athetosis

is movement characterized by slow irregular twisting motions

S4

is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults.

Tinea capitis

is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin caused by a fungal infection.

chorea

is spontaneous brief, involuntary muscle twitching of the limbs or facial muscles

disuse syndrome

is the generic name for a physical state caused by bed rest, immobility and/or a lack of physical activity.

Eupnea

means a normal breathing pattern

Audiometry

measures hearing acuity at different sound frequencies

egophony, bronchophony

occur when there is consolidation or atelectasis present

Egophony

occurs when the client says "ee" and the nurse hears the sound "ay."

pulmonary edema

patients with forth pink secretions suffer from?

infection

patients with sputum that is yellow or green or has a putrid or musty odor may indicate what

asthma

patients with stringing sputum, like thickened egg white have?

sphygmomanometer

the _________ is used to assess blood pressure.

immobilizer

the nurse is caring for a 19-year-old client who sustained a knee sprain while playing college sports. Which type of splint does the nurse anticipate will be ordered to support the knee while it heals? -immobilizer -inflatable -molded -traction

1+ pitting edema

there is a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30% above normal.

5+ brawny edema

there is no pitting; tissue palpates as firm or hard, and the skin surface appears shiny, warm, and moist.

Vancomycin-resistant enterococci (VRE)

these are a type of bacteria called enterococci that have developed resistance to many antibiotics, especially vancomycin. transmitted via contact

Neutrophils

these are an important link in generating fever to combat the proliferation of microorganisms.

T lymphocytes

these are important in the synthesis of immunoglobulins.

A comprehensive assessment with a detailed health history and complete physical examination

these are usually conducted when a client enters a health care setting

Eosinophils

these increase in response to allergic and parasitic conditions when an antigen-antibody response occurs.

Immobilizers

these limit motion in the area of a painful but healing injury.

Traction splints

these types of splints are metal devices that immobilize

Inflatable splints

these types of splints become rigid when filled with air

poorly hydrated

thick and sticky sputum is usually difficult to expectorate and may indicate that the patient is?

kussmual

this condition is caused by metabolic acidosis, diabetic ketoacidosis, renal failure

biot's

this condition is caused by neurologic problems (meningitis, encephalitis), head trauma, brain, abscess, heatstroke

Vesicular sounds

this sound is soft and low-pitched, with longer inspiration than expiration.

spica cast

this type of cast encircles one or both legs, but when applied to a lower extremity, the cast is trimmed in the anal and genital areas to allow for the elimination of urine and stool

noncommunicable disease

this type of disease is caused by food or environmental toxin.

Isotonic

this type of exercise is a dynamic form of exercise with constant muscle tension, muscle contraction, and active movement

Standard precautions

this type of precautions apply to blood and all body fluids, secretions, and excretions, except sweat.

Neutropenic precautions

this type of precautions are used for clients with compromised immune systems. Such clients may be recovering from a transplant or receiving chemotherapy

transmission-based precautions

this type of precautions are used in addition to standard precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes

Bronchial breath sounds

this type of sound is high pitched, with expiration longer than inspiration.

Adventitious sounds

this type of sound is not normally heard in the lungs

molded splint

this type of splint is an orthotic device made of rigid materials that is used for treatment of chronic injuries accompanied by inflammation, such as carpal tunnel syndrome.

manual traction

this type of traction is to provide a very specific and controlled distraction force to the spine or joint in order to alleviate pain or compression. It can help with the "pinch" of a herniated disc or the compression that occurs in an arthritic knee.

stomach

tympany is a high-pitched, loud, drumlike sound produced over the

catabolic state

unrelieved pain produces a?

glasgow coma scale (GCS)

used when testing the level of consciousness

cramping

what S/S signs and symptoms would you expect for someone with Low potassium?

bradycardia

what S/S signs and symptoms would you expect for someone with high potassium.?

Provocative or palliative ("What makes it better or worse?")

what does the P stand for in PQRST

Quality or quantity ("What is it like?")

what does the Q stand for in PQRST

Region or radiation ("Where is it?" "Where does it radiate?")

what does the R stand for in PQRST

Severity ("How bad is it?")

what does the S stand for in PQRST

Timing ("When did it start?" "How often?")

what does the T stand for in PQRST

progesterone, thyroxine, epinephrine, norepinephrine

what four hormones elevate body temperature by increasing heat production

airway

what is always your first priority?

Convalescence

what phase completes the progress of an infection.

Rinne test

what test compares the air versus bone conduction of sound, as well as testing air conduction of sound in the tested ear.

three-point non-weight-bearing gait

what type of crutch can be observed in clients with one amputated, injured, or disabled extremity.

round white or pink

what would you expect to see when looking at the optic nerve disc

false low

when dealing with blood pressure and using a cuff that is too large it results in what type of reading

false high

when dealing with blood pressure and using a cuff that is too small or loosely applied it results in what type of reading

dilate

when looking at an object in the distance the eyes will?

to identify a life-threatening problem

-to facilitate the resident's ability to breathe -to identify a life-threatening problem -to practice respiratory assessment skills -to establish a database for medical care

a dysrhythmia

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of: -a dysrhythmia. -hypertension. -tachycardia. -bradycardia.

Wheezes

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? -Fine crackles -Pleural friction rub -Stertorous breathing -Wheezes

diminished, thready

A nurse is assessing the pulses of a client's lower extremities and finds that the client's popliteal pulses are 1+. The nurse interprets this finding as: -absent. -increased, full volume. -normal. -diminished, thready.

direct contact

A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by: -direct contact. -vectors. -indirect contact. -airborne route.

Urine sample

A nurse is cleaning the room of a client with tuberculosis. Which item can the nurse dispose of as biodegradable trash? -Specimen containers -Soiled linen -Urine sample -Plastic bedpans

Pathogenicity

___ is an organism's ability to cause infections

kyphosis

"dowager's hump," is an unnatural curving of the upper back that creates a hunchback appearance

Bacteria

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which agent is most likely the cause of the infection? -Fungi -Bacteria -Virus -Spores

Chill

A nursing instructor is describing the phases of a febrile episode. What would the instructor describe as happening first? -Chill -Flush -Crisis -Fever

two-point gait

Clients who have more coordination and balance are more likely to have what type of crutch.

tympanic thermometer

Cold body temperature is best measured with what type of thermometer

pneumonia or heart failure

Crackles (short, high-pitched popping sounds) may indicate disease, such as

subtracting the client's age from 220

Maximum heart rate is calculated by?

1,000

Neutropenia is present when the absolute neutrophil count (ANC) falls to fewer than _____ cells/mm3

temperature 100.0º F (37.78º C)

The home care nurse is assessing a client's vital signs at rest. Which finding requires nursing intervention? -pulse rate 70 beats per minute -respirations 18 per minute -temperature 100.0º F (37.78º C) -blood pressure 116/80 mm Hg

contact

The nurse is caring for a client with a acute viral conjunctivitis. Which precautions will the nurse begin? -droplet -airborne -contact -none

Exercise

Which condition will lead to an increase in cardiac output? -Sleep -Decrease in blood pressure -Dehydration -Exercise

Depth

Which is not a characteristic used to describe the pulse? -Rhythm -Frequency -Quality -Depth

impaired circulation

an asymmetric pulse is seen in?

romberg test

this test deals with balance

a reduction in the facility's funding from the Centers for Medicare & Medicaid Services (CMS)

A care facility has been the site of three Norovirus outbreaks over the past several months, resulting in the highest incidence and prevalence of this infection in the region. This phenomenon may result in: -a disciplinary hearing under the scope of the Occupational Safety and Health Administration (OSHA). -fines levied by the Centers for Disease Control and Prevention (CDC). -a safety audit by the state's board of nursing. -a reduction in the facility's funding from the Centers for Medicare & Medicaid Services (CMS).

Peripheral vascular disease

A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.

"Dizziness when you change position can occur when fluid volume in the body is decreased."

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? -"Dizziness can occur when baroreceptors overreact to the changes in BP." -"Dizziness can occur due to changes in the hospital environment." -"Dizziness when you change position can occur when fluid volume in the body is decreased." -"Dizziness is caused by very low blood pressure when you lay down."

Focused assessment

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform? -Initial assessment -Time-lapse assessment -Emergency assessment -Focused assessment

Admission assessment

A client comes to the acute care facility for diagnostic testing and elective surgery. Which type of assessment would the nurse most likely complete? -Time-lapse reassessment -Emergency assessment -Admission assessment -Focus assessment

Focused

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? -Time-lapse -Emergency -Head-to-toe -Focused

partially obstructed blood flow through a valve opening

A nurse is performing a cardiac assessment. While auscultating the chest, the nurse hears swishing sounds through the stethoscope, resembling systolic murmurs. What would the nurse suspect? -partially obstructed blood flow through a valve opening -forward blood flow caused by a leaky valve -blood flow through a normal opening between heart chambers -reduced blood flow across a normal valve

Intact skin and mucous membranes protect against microbial invasion

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection? -Intact skin and mucous membranes protect against microbial invasion. -Age, race, sex, and hereditary factors influence susceptibility to infection. -White blood cells provide resistance to certain pathogens. -Stress may adversely affect normal defense mechanisms.

Stand 2 feet behind and to the side of the client

A nurse is performing a whisper test on an elderly client. How should the nurse complete this assessment? -Place headphones on the client to listen for recorded sounds. -Stand 2 feet behind and to the side of the client. -Stand in front of the client and have them close their eyes. -Place a vibrating tuning fork on top of the client's head.

The client will state how to safely take the prescribed antibiotic

A client has a nursing diagnosis of Deficient Knowledge related to prescribed antibiotic therapy. Which outcome would the nurse identify as most appropriate? -The client will identify signs and symptoms of worsening infection. -The client will state how to safely take the prescribed antibiotic. -The client will verbalize measures appropriate to minimize infection transmission. -The client demonstrates the proper technique for hand hygiene.

raking leaves

A client has been prescribed exercise at the metabolic energy equivalent (MET) of 3. Which exercise type will the nurse recommend? -bowling -playing contact football -shoveling snow -raking leaves

slow swimming

A client has been prescribed exercise at the metabolic energy equivalent (MET) of 5. Which exercise type will the nurse recommend? -playing basketball -slow swimming -golfing with a cart -dressing self

liver

A medium dull sound is heard over the

stroke

A middle-age, overweight adult client has had hypertension for 15 years. The pathologic event the client is most at risk for is: -cancer. -anemia. -stroke. -infection.

a bruit

A nurse is performing auscultation during the physical examination of a client. The nurse most likely would be assessing: -a bruit -tenderness near spine -shape of liver -size of thyroid

Encourage active exercise with a bed trapeze

A nurse is assessing a client after knee surgery in a health care facility. Which intervention should the nurse follow to avoid complications associated with disuse syndrome? -Encourage active exercise with a bed trapeze. -Reposition the client every 4 hours. -Follow a rigid daily routine for the client. -Use a gel mattress on the bed.

Healthcare-associated infection (HAI)

A client in the ICU has a central venous catheter in place. The client has now become septic with no obvious cause or source of infection. Antibiotic therapy does not help resolve the sepsis. What would the nurse suspect that the client has most likely developed? -secondary bloodstream infection -vancomycin-resistant enterococcus (VRE) -methicillin-resistant staphylococcus aureus (MRSA) -Healthcare-associated infection (HAI)

Start contact precaution protocol and place a sign by the door, Allocate a vital signs machine for the client's room

A client is admitted with Clostridium difficile (C. difficile) with frequent loose stool and fever. Which action should the nurse implement for this client? Select all that apply. -Request for stool softener to prevent constipation. -Initiate the first dose of antiviral medication quickly. -Start contact precaution protocol and place a sign by the door. -Instruct the unlicensed assistive personnel (UAP) to strictly use hand sanitizer when entering the room. -Allocate a vital signs machine for the client's room.

3 days

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for: -3 days. -5 days. -4 days. -2 days.

completing a mental status assessment

A client is brought to the emergency department after being hit in the head with a bat during a softball game. What is the nurse's priority assessment? -checking peripheral pulses -auscultating the heart and lungs -assessing vital signs -completing a mental status assessment

Provide gentle oral care, Keep the door closed, Remove any fresh flowers from the client's room

A client is placed on neutropenic precautions. What would be appropriate for the nurse to do? Select all that apply. -Allow open visitation from family and friends. -Provide gentle oral care. -Place the client in a room with another client with neutropenia. -Keep the door closed. -Remove any fresh flowers from the client's room.

in the acute phase.

A client presents to the clinic reporting fever and abdominal pain. Blood work shows an elevated white count. This client is: -in the disorganized phase. -in the acute phase. -in the colonized phase. -in the inflamed phase.

Inform the physician about this finding

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next? -Inform the physician about this finding. -Encourage the client to brush his teeth 3 times a day. -Inform the client that the antibiotics will resolve this problem. -Assess for the expiration dates of the antibiotics being administered.

Client himself

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? -Client's friends -Client himself -Test reports -Client's wife

focuses on client's normal, altered, and risk for altered function

A client visits the health care facility for a regular check-up. The nurse integrates the functional health pattern model when assessing the client. Which nursing action best describes how the nurse collects and organizes the data? -assesses the general state of health, then each body system -focuses on client's normal, altered, and risk for altered function -examines every body part systematically from the head to toe -focuses on function of major anatomic systems of the body

"Stress leads to increased secretion of cortisol, which suppreses your immune response."

A client who comes to the clinic asks the nurse, "Somebody told me that stress increases my risk for infection. How does this happen?" Which response by the nurse would be most appropriate? -"Stress leads to a deterioration in the skin's barrier line of defense." -"Stress causes body fluids to accumulate, which leads to bacterial growth." -"Stress causes the body's normal immune response to turn on itself." -"Stress leads to increased secretion of cortisol, which suppreses your immune response."

"How long have you had the infection?"

A client who thinks he has an infection has come to the clinic. During the assessment, which question would the nurse most likely ask first? -"Are you having any general aches or fatigue?" -"Do you have a fever?" -"How long have you had the infection?" -"Do you have any pain or swelling?"

Palpate the liver for enlargement

A nurse is assessing a client and observes jaundice on the skin and hard palate on the sclera bilaterally. What is the appropriate action of the nurse? -Auscultate the lungs for crackles. -Palpate the liver for enlargement. -Percuss the spleen for tenderness. -Assess the client's temperature.

manual

A client with a dislocated shoulder has come to the emergency department (ED) in extreme pain. Which type of traction will the nurse prepare to be used? -skeletal -Russell's -Buck's -manual

"Your white blood cells have increased in the area."

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate? -"Metabolism in your wound tissues is increased." -"Your white blood cells have increased in the area." -"It's just a sign that your wound is infected." -"It results from the swelling caused by the pain of the inflammation.

three-point partial-weight-bearing gait

A client with an amputated limb learning to use a prosthesis would have what type of crutch

functional brace

A client with an unstable patella has seen the healthcare provider to discuss options to provide stability to this joint. Which type of immobilizer does the nurse anticipate applying? -functional brace -inflatable splint -rehabilitative brace -cylinder cast

one crutch, opposite foot, other crutch, remaining foo

A client with arthritis has been prescribed four-point crutch-walking. Which teaching regarding gait pattern will the nurse provide? -one crutch and opposite foot moved in unison, followed by remaining pair -both crutches are moved forward, one or both legs are advanced beyond crutches -one crutch, opposite foot, other crutch, remaining foot -both crutches move forward, followed by the weight-bearing leg

trochanter rolls

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? -foot splints -roller sheets -trochanter rolls -foot boards

both crutches are moved forward, one or both legs are advanced beyond crutches

A client with paralysis has been prescribed swing-through crutch-walking. Which teaching regarding gait pattern will the nurse provide? -both crutches move forward, followed by the weight-bearing leg -one crutch and opposite foot moved in unison, followed by remaining pair -one crutch, opposite foot, other crutch, remaining foot -both crutches are moved forward, one or both legs are advanced beyond crutches

10,000

A community health nurse is teaching a 22-year-old healthy client about activity monitoring with a self-monitoring motion sensing device. The nurse will recommend the client set a daily goal for how many steps? -10,000 -1000 -5000 -15,000

6000

A community health nurse is teaching a 42-year-old sedentary client about activity monitoring with a self-monitoring motion sensing device. The nurse will recommend the client set an initial daily goal for how many steps? -7600 -6000 -11,000 -14,000

The incident report will be used to inform changes so that the dirty supply room becomes less accessible to clients

A confused client entered the dirty supply room on the unit and was found rummaging through trash that contained blood and body fluids. An incident report has been completed about this event by the nurse who discovered the client. Which statement about the incident report is most accurate? -The incident report is completed anonymously, allowing the nurse to be frank with suggestions. -The incident report will be used to inform changes so that the dirty supply room becomes less accessible to clients. -The nurse's priority in completing the report is justifying and explaining her initial response to the incident. -The incident report becomes an attachment to the client's health record.

(1) the chill phase, (2) the fever phase, and (3) the flush phase or crisis

A febrile episode has three distinct phases: what are those phases in order

T-lymphocytes

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins? -Neutrophils -Eosinophils -Monocytes -T-lymphocytes

reactivate if the same antigen reappears

A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identfy what as a function of cellular immunity? -reactivate if the same antigen reappears -enhance phagocytosis of microbes -help lysis of bacterial cell walls -encourage inflammatory response

giving an overview of the client's circumstances and the exact reason for the call

A hospital client's urine output is 35 mL over the past 5 hours, so the nurse has chosen to inform the client's primary care provider by telephone. The nurse will use the SBAR tool to communicate, so will begin the dialogue by: -explaining the client's symptoms and suggesting a preliminary plan. -describing the major objective signs that the client is exhibiting. -giving an overview of the client's circumstances and the exact reason for the call. - introducing the client and listing the client's current medications.

elevating the stump to prevent pressure ulcers

A male client is admitted to the unit following an amputation of his left leg below the knee. The nurse responsible for him is developing his nursing plan of care. This plan of care should not include: -teaching the client to use a trapeze for transfers. -encouraging ROM at least every 8 hours. -elevating the stump to prevent pressure ulcers. -involving physical therapy in the plan of care.

"Why did no one in the room choose to call a code?"

A neonate was born by vaginal birth and initial assessment revealed no distress. However, the infant soon developed dyspnea and then apnea. The care team in the room attempted to manage the infant's distress independently and neglected to call an emergency code, which was later determined to be necessary. Root cause analysis of this event should begin by asking what question? -"Was this team experienced in dealing with neonatal distress?" -"How would an emergency code have prevented harm to this infant?" -"Would a cesarean birth have been more appropriate than vaginal birth?" -"Why did no one in the room choose to call a code?"

Collection of subjective data, Complete set of vital signs, Functional ability evaluation

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply. -Goals with outcome criteria -Collection of subjective data -Complete set of vital signs -Description of client education -Functional ability evaluation

Auscultation

A nurse assesses a client for blood pressure. Which technique would be used for this assessment? -Auscultation -Palpation -Percussion -Inspection

Extraocular movements

A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process? -Existence of cataracts -Extraocular movements -Peripheral vision -Visual acuity

Client

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source? -Health care records -Client -Primary care physician -Client's spouse

Soft, low-pitched, whispering sounds heard over most of the lung fields, Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly, Blowing, hollow sounds auscultated over the larynx and trachea

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply. -Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration -Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration -Blowing, hollow sounds auscultated over the larynx and trachea -Soft, low-pitched, whispering sounds heard over most of the lung fields -Bubbling, crackling, or popping sounds auscultated during inspiration and expiration -Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly

clients with disabilities such as arthritis or cerebral palsy

A nurse at a health care facility is caring for clients using crutches to ambulate. In which client would the nurse observe a four-point walking gait? -clients who have more coordination and balance -clients with amputated limbs who are learning to use prosthetic limbs -clients with disabilities such as arthritis or cerebral palsy -clients with one amputated, injured, or disabled extremity

Focused assessment

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? -Focused assessment -Emergency assessment -Initial assessment -Time-lapse reassessment

Wipe with isopropyl alcohol

A nurse has been asked to record a client's body temperature every hour using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer? -Soak in water mixed with alcohol. -Wash with soap and water followed by alcohol. -Soak in isopropyl alcohol. -Wipe with isopropyl alcohol.

Break the needle off at the hub after recapping it

A nurse has just given an injection to a client and is preparing to dispose of the needle and syringe. Which action would be least appropriate for the nurse to do? -Use a one-handed scoop method. -Dispose of the needle and syringe in a puncture resistant container. -Break the needle off at the hub after recapping it. -Replace the retractable needle-guard.

2,500 cells/mm3

A nurse in an oncology care unit is reviewing the laboratory test results of several clients scheduled to receive chemotherapy. The nurse determines that the client with which leukocyte count will most likely have the chemotherapy withheld? -9,800 cells/mm3 -2,500 cells/mm3 -7,500 cells/mm3 -5,800 cells/mm3

18,000 cells/mm

A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The nurse identifies that the client with which leukocyte count most likely has an infection? -5,000 cells/mm -18,000 cells/mm -10,000 cells/mm -8,000 cells/mm

Interview

A nurse is assessing a client admitted to the health care facility with angina. Which method would be most appropriate for the nurse to use to collect subjective data? -Interview -Stethoscope -Laboratory studies -Scale

Evidence of pain, Sensory function, Hearing, Memory

A nurse is assessing a client using the functional health patterns model. Which would the nurse include when assessing the client's cognition and perception? Select all that apply. -Hearing -Memory -Evidence of pain -Exercise routine -Sensory function -Appraisal of appetite

determines the equality or disparity of bone-conducted sound

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test? -compares air versus bone conduction of sound -tests air conduction of sound in the tested ear -measures hearing acuity at various sound frequencies -determines the equality or disparity of bone-conducted sound

Adds depth to existing information

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment? -Gives a comprehensive volume of data -Suggests possible problems -Adds depth to existing information -Provides breadth for future comparisons

heart rate 110 bpm, respiratory rate 26 breaths/min, PaCO2 28 mm Hg

A nurse is assessing a client with suspected sepsis. What would the nurse most likely find? Select all that apply. -respiratory rate 26 breaths/min -White blood cell count 9,000 -Temperature 37°C -heart rate 110 bpm -PaCO2 28 mm Hg

whether they have a program of regular physical activity

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? -whether they have a program of regular physical activity -whether they have proper dietary habits -whether they have anemia -whether they have home maintenance skills

There is an auscultatory gap

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? -There is a widening in the diameter of the artery. -There is an adult diastolic pressure. -There is a nonauscultatory gap. -There is an auscultatory gap.

the ability of the arteries to stretch

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? -the oxygen levels in the blood -the ability of the arteries to stretch -the thickness of circulating blood -the volume of air entering the lungs

The reading is erroneously high

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? -The pressure on the cuff will be painful. -The reading is erroneously high. -The reading is erroneously low. -It will be difficult to pump up the bladder.

shorter on inspiration than expiration, with a pause between them

A nurse is assessing the lung sounds of a client with respiratory disorders. What is a normal bronchial sound? -shorter on inspiration than expiration, with a pause between them -equal in length during inspiration and expiration, separated by a brief pause -longer on inspiration than expiration, with no noticeable pause -equal in length during inspiration and expiration, with no noticeable pause

Document normal breath sounds

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? -Recommend testing for pneumonia. -Assess for asthma. -Suspect an inflamed pleura rubbing against the chest wall. -Document normal breath sounds.

Document normal breath sounds

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? -Recommend testing for pneumonia. -Document normal breath sounds. -Suspect an inflamed pleura rubbing against the chest wall. -Assess for asthma.

Pulse is felt with difficulty and disappears with slight pressure

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? -Pulse is felt easily, and moderate pressure causes it to disappear. -Pulse is strong, and light pressure causes it to disappear. -Pulse is strong and remains strong despite moderate pressure. -Pulse is felt with difficulty and disappears with slight pressure.

Brain function is within normal limits

A nurse is assessing the pupillary response of a client brought into the emergency department with a head injury. Both pupils are round and react to light. What can the nurse interpret about the client's neurological status based on this data? -The client has 20/20 vision. -Brain function is within normal limits. -The client should be referred to an ophthalmologist. -Cranial nerve #1 is intact.

Erythema

A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding? -Erythema -Flushed -Pallor -Ecchymosis

Gray, Blue, Purple

A nurse is assessing the skin of a middle-age client with hypoxia. Which color could the skin of this client be? Select all that apply. -Yellow -Purple -Gray -Blue -Red

The shoulder and upper back curves forward

A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture? -The sacral region tends to turn outward. -The shoulder and upper back curves forward. -The lumbar region tends to curve inward. -A portion of the spine is curved to the side laterally.

newborns and children using abdominal muscles during respirations older adults having an increased anterior-posterior (AP) chest diameter older adults having an increase in the dorsal spinal curve (kyphosis)

A nurse is assessing the thorax and lungs of clients visiting a physician's office. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply. -older adults having increased thoracic expansion -softer auscultated breath sounds found in newborns and children -children under 10 having a slower respiratory rate than an adult -newborns and children using abdominal muscles during respirations -older adults having an increase in the dorsal spinal curve (kyphosis) -older adults having an increased anterior-posterior (AP) chest diameter

isometric

A nurse is providing care to a client who has a cast on his leg. While educating the client on how to perform quadriceps setting exercises to strengthen the quadriceps muscle, he asks, "What kind of exercise is this?" The nurse identifies this type of exercise as: -aerobic. -isotonic. -isometric. -anaerobic.

to maintain safety should the client become dizzy or faint

A nurse is assisting a client at a health care facility dangle his legs before he ambulates. The nurse places the client in Fowler's position for a few minutes. What is a possible reason for this action? -to allow the client to use the floor for support -to help the client's heart rate stabilize -to give the client time to mentally focus on the task -to maintain safety should the client become dizzy or faint

A reddish retina

A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? -A clear, reddish optic nerve disc -A uniform yellow reflex -Dark-red arteries and light-red veins -A reddish retina

Bronchophony

A nurse is auscultating a client's chest and notices adventitious breath sounds. The nurse suspects atelectasis and asks the client to repeat the word "ninety-nine." The nurse hears the sound louder and more clearly than normal. The nurse documents this as: -Crackles -Wheezes -Bronchophony -Egophony

Crackles are audible in the posterior bases bilaterally and they are abnormal

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings?

Crackles are audible in the posterior bases bilaterally and they are abnormal

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings? -Crackles are audible in the posterior bases bilaterally and they are abnormal. -Gurgling is occurring in the lower posterior lobes indicating the client needs to cough. -Bronchovesicular breath sounds are audible in the posterior lobes. -Pleural friction rub is occurring in the posterior middle lower lobes.

Perform hand hygiene and apply personal protective equipment

A nurse is beginning a physical exam on a child who is admitted to the pediatric unit with suspected meningococcal meningitis. What is the nurse's priority action? -Begin with assessment of vital signs. -Perform hand hygiene and apply personal protective equipment. -Allow the child to examine the instruments. -Gather and sterilize equipment.

5,850 mL (5,850 × 109/L)

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? -6,000 mL (6,000 × 109/L) -5,000 mL (5,000 × 109/L) -5,550 mL (5,500 × 109/L) -5,850 mL (5,850 × 109/L)

makes problems more easily identifiable, as findings tend to be clustered

A nurse is caring for a client reporting lower back pain. The nurse uses the body systems approach to assess the client. What are the advantages of using this approach for data collection? -makes problems more easily identifiable, as findings tend to be clustered -reduces the number of position changes required of the client -prevents overlooking certain aspects of data collection -takes less time, as the nurse is not constantly moving around the client

Proteins

A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature? -Fiber -Minerals -Proteins -Vitamins

obtaining rectal temperatures

A nurse is caring for a client who has neutropenia resulting from chemotherapy. Which precaution would be least appropriate to include when caring for this client? -avoiding razors with blades -providing gentle oral care -encourage wearing a mask when out of the room -obtaining rectal temperatures

The nurse places the client in a private room with monitored negative air pressure

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety? -The nurse places the client in a private room with the door open. -The nurse uses droplet precautions when providing care for the client. -The nurse keeps visitors 3 feet away from the infected person. -The nurse places the client in a private room with monitored negative air pressure.

Dilated pupils

A nurse is caring for a client who is experiencing acute pain in the lower back. Which condition would the nurse interpret as an objective finding that correlates with the client's pain? -High fever -Low blood pressure -Dilated pupils -Reduced pulse

On the mastoid area

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? -Near the ear canal -Center of the head -Behind the client's head -On the mastoid area

The sounds are equal in length and are separated by a brief pause

A nurse is caring for a client with respiratory disorders. How would the nurse be able to distinguish tracheal sounds from the other sounds in the lungs when listening to lung sounds? -The sounds are shorter on inspiration than expiration, with a pause between them. -The sounds are soft and rustling, longer on inspiration than expiration, with no pause between them. -The sounds are equal in length and are separated by a brief pause. -The sounds are medium-range sounds of equal length, with no noticeable pause.

Fungi

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? -Protozoans -Rickettsiae -Fungi -Helminths

Dyspnea

A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition? -Apnea -Hyperventilation -Dyspnea -Hypoventilation

inspecting the abdominal incision, taking the client's blood pressure, reviewing morning lab results

A nurse is caring for a post-operative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? (Select all that apply.) -helping the client to bathe and brush teeth -reviewing morning lab results -inspecting the abdominal incision -taking the client's blood pressure -assisting the client to sit up in a chair

"Mr. Koeppe, tell me what you do to take care of yourself."

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement by the nurse would recognize the client's value as an individual? -"Mr. Koeppe, I know you can't answer my questions, but it's okay." -"Mr. Koeppe, tell me what you do to take care of yourself." -"Sarah, I have to go and read your father's old charts before we talk." - "Can you tell me how long your father has been this way?"

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond? -"Your vision in your right eye is slightly different than that of your left eye." -"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." -"Your vision is perfect; you can read the entire chart and you do not need glasses." -"Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)."

height and weight

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening? -calorie count -height and weight -abdominal girth -vital signs

Percussion

A nurse is conducting a physical examination and is determining the location and level of the liver. Which technique would the nurse most likely use? -Palpation -Percussion -Auscultation -Inspection

Tympany

A nurse is conducting a physical examination and is percussing the gastric area of a client. What percussion tone is normally heard in this area? -Tympany -Dull -Flat -Resonant

to identify problematic functional health patterns

A nurse is conducting an admission assessment of a client who has come to the primary care clinic. The nurse conducts this assessment for which reason? -to identify problematic functional health patterns -to determine the client's medical diagnosis -to identify possible life-threatening situations -to evaluate changes in functional health

client hears vibrations in the affected ear

A nurse is conducting an auditory assessment of an older adult with a conductive hearing loss. The nurse performs the Weber test. Which finding would the nurse expect to assess in this client? -client hears vibrations in the affected ear -client hears sound that is lateralized to the unaffected ear -client hears vibrations equally in both ears -client hears a hyperresonant sound in both the ears

"What is your problem as you see it?"

A nurse is conducting an interview with a client who reports abdominal distress. What is an appropriate interview question for this client?

humoral immunity

A nurse is developing a presentation for a local community group about infections and resistance to them. When describing acquired specific defenses, what would the nurse most likely include?

oriented to person, place, and time

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? -oriented to person, place, and situation -oriented to hospital, person, and date -oriented to person, place, and time -oriented person, situation, and time

3+ pitting edema

A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding? -2+ pitting edema -5+ brawny edema -1+ pitting edema -3+ pitting edema

Orthostatic hypotension

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur? -Primary hypertension -Secondary hypertension -Orthostatic hypotension -Dyspnea

to prevent or reduce the severity of a joint injury

A nurse is fitting prophylactic braces to a client. What is the major function of prophylactic braces? -to allow protected motion of an injured joint -to provide stability for an unstable joint -to allow for the elimination of urine and stool -to prevent or reduce the severity of a joint injury

Wet the chest hair and auscultate with the chest piece

A nurse is having difficulty hearing lung sounds on a client with a large amount of chest hair. What is the appropriate action of the nurse? -Cut the chest hair and press firmly with the chest piece. -Ask another nurse to evaluate the client's lung sounds. -Auscultate using the bell of the stethoscope. -Wet the chest hair and auscultate with the chest piece.

Gently pull the pinna down and back

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization? -Pull the pinna parallel to the side of the head. -There is no need to move the pinna. -Gently pull the pinna up and back. -Gently pull the pinna down and back.

The nurse assesses the client's comfort and ability to participate in the interview

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? -The nurse assesses the client's comfort and ability to participate in the interview. -The nurse gathers all the information needed to form the subjective database. -The nurse recapitulates the interview, highlighting important points. -The nurse ensures the environment for the interview is comfortable and private.

Rubs

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these? -Crackles -Wheezes -Rubs -Gurgles

rubs

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these? -Wheezes -Rubs -Crackles -Gurgles

Semi-Fowler's

A nurse is providing postoperative care for a client who is immobilized due to rod fixation. The nurse would place the client in which position? -Reverse Trendelenburg's -Semi-Fowler's -Dorsal recumbent -Trendelenburg's

Flexion and extension

A nurse is performing range-of-motion (ROM) exercises for a comatose client. The nurse bends the client's arm to decrease the angle between two adjoining bones and then straightens it to increase the angle between two adjoining bones up to 180 degrees. Which joint motions are involved in this type of movement? -Inversion and eversion -Abduction and adduction -Flexion and extension -Plantar flexion and dorsiflexion

coordinated movement of both eyes

A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe? -coordinated movement of both eyes -nystagmus in all positions -convergence of the eyes -constriction of both pupils

Use an electronic bed scale

A nurse is planning to obtain a weight on an obese client who has a history of falls. What is the best way to obtain the client's weight? -Transfer the client to a chair scale. -Delegate this task to the assistive personal. -Assist the client to stand on a scale at the bedside. -Use an electronic bed scale.

Use sterile gloves to handle the entire drape surface

A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. What is an appropriate technique for this procedure? -Fold the lower edges of the drape over the sterile-gloved hands. -Touch only the outer 2 in (5 cm) of the drape when not wearing sterile gloves. -When reaching over the drape do not allow clothing to touch the drape. -Use sterile gloves to handle the entire drape surface.

Facing away from the body

A nurse is preparing a sterile field and has removed the sterile drape from the outer wrapper. The nurse places the inner drape in the center of the work surface with the outer flap facing in which direction? -Angled to the left side -Facing toward the body -Facing away from the body -Toward the right side

intravenous antibiotic adminstration

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan? -intravenous antibiotic adminstration -hand hygiene measures -vital sign monitoring -signs and symptoms of infection

papule is an elevated palpable solid mass, vesicle is an elevated, round lesion filled with serum, nodule is an elevated solid mass

A nurse is preparing for a skin care certification course and needs to correctly identify various lesions that may be seen on the skin. Which definitions are correct? (Select all that apply.) -vesicle is an elevated, round lesion filled with serum -cyst is an elevated, circumscribed lesion filled with fluid -wheal is an elevated round, solid mass under the skin -nodule is an elevated solid mass -papule is an elevated palpable solid mass

gloves, stethoscope, pen light

A nurse is preparing to complete a basic physical assessment. Which supplies will the nurse gather before preparing the client? (Select all that apply.) -pen light -ophthalmoscope -Snellen chart -stethoscope -gloves

inspection

A nurse is preparing to complete an assessment on a client with a history of heart disease. Which technique will the nurse use to begin the assessment? -palpation -percussion -auscultation -inspection

deciding what data are needed, assessing own feelings about previous clients, modifying the environment for the interview

A nurse is preparing to conduct an interview of a newly admitted client. Which actions would the nurse be taking? Select all that apply. -introducing self to the client -deciding what data are needed - informing client about the expected time frame -modifying the environment for the interview -assessing own feelings about previous clients

"What brings you here today?"

A nurse is preparing to conduct the health history for a client new to the clinic. Which question would the nurse likely ask first? -"What are your usual activities each day?" -"How would you describe your health?" -"What brings you here today?" -"Do you have any pain or discomfort?"

selecting an appropriate vein and establishing access aseptically

A nurse is preparing to insert a peripheral intravenous (IV) into a client who requires IV fluids. How can the nurse best demonstrate the skills that indicate the nurse meets the Quality and Safety Education for Nurses (QSEN) competency of safety? -selecting an appropriate vein and establishing access aseptically -being aware of the signs of infiltration and other complications of therapy -having empathy for the client and recognizing that the procedure is painful -knowing the assessment findings that indicate therapy has been successful

uses broad, open statements to communicate with the client

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: -reassures the client of good outcomes. -attempts to write down everything the client says. -agrees with each of the client's statements. -uses broad, open statements to communicate with the client.

Clear exudate from around the wound.

A nurse is preparing to obtain an aerobic wound culture from a client's surgical site. What would be most important for the nurse to do to ensure that the results are accurate? -Clear exudate from around the wound. -Wear sterile gloves to obtain the needed specimen. -Crush the medium ampule before removing the culture swab. -Irrigate the wound with hydrogen peroxide.

Allow the tops of the culture bottles to dry after cleaning. Change the needle on the syringe containing the specimen before inoculating the culture bottles. Use two different venipuncture sites for the specimen collection

A nurse is preparing to obtain blood cultures from a client with an infection. Which action would be important for the nurse to do? Select all that apply. -Change the needle on the syringe containing the specimen before inoculating the culture bottles. -Allow the tops of the culture bottles to dry after cleaning. -Obtain the specimen immediately after the client's temperature goes down. -Vigorously cleanse the specimen port on the client's current intravascular line. -Use two different venipuncture sites for the specimen collection.

supine with knees slightly flexed and arms at the side

A nurse is preparing to palpate a client's abdomen. To ensure accuracy of the assessment, the nurse would place the client in which position? -semi-Fowler's with hips flexed and arms raised behind the back of the head -supine with legs extended and arms crossed over chest -side-lying with knees flexed and arms extended upward -supine with knees slightly flexed and arms at the side

This action is a violation of Occupational Safety and Health Administration (OSHA) regulations

A nurse manager has received an incident report that describes intravenous tubing containing chemotherapeutics being found in the regular trash, rather than in the specially designated receptacle. Which statement accurately describes an aspect of this situation? -This action is a violation of Occupational Safety and Health Administration (OSHA) regulations. -This action is a serious breach of protocol that could possibly result in criminal charges. -The hospital where this occurred is likely to lose Centers for Medicare & Medicaid Services (CMS) funding. -A root cause analysis will determine which staff member committed this error.

The nurse demonstrated reckless behavior by not admitting the error

A nurse mistakenly gave a client an immediate dose of an opioid, rather than the extended release form of the drug. The client developed respiratory depression that required resuscitation. The nurse did not admit to the error until forced to weeks later by persistent rumors among colleagues. Which statement about this nurse's actions is most accurate? -The nurse demonstrated at-risk behavior by covering up the error. -The nurse demonstrated reckless behavior by administering the wrong version of the medication. -The nurse demonstrated human error by the attempts to cover up the mistake. -The nurse demonstrated reckless behavior by not admitting the error.

Over the client's thigh

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? -Over the client's thigh -Brachial artery -Radial artery -Over the lower arm

Pour and discard a small amount of the solution

A nurse needs to visit the intensive care unit to administer an enema to a client. Which step should the nurse take when using the sterile solution located at the entrance to the intensive care unit? -Loosen the cap or the seal on the bottle. -Clean the nozzle area with a damp cloth. -Pour and discard a small amount of the solution. -Hold the container from the top.

The body produces white blood cells

A nurse notes that a client who is being treated for a puncture wound at a health care facility is in the second stage of the inflammatory phase. The nurse should know that which function is a part of the second stage of inflammation? -The body produces white blood cells. -Damaged cells become permeable. -Blood vessels constrict to control blood loss. -Blood vessels dilate to deliver platelets

Occupational Safety and Health Administration (OSHA)

A nurse observed a client fall in the hallway. After assessing the client's status, the nurse assisted the client off the floor and in doing so sustained a back injury. This injury primarily falls within the scope of what government agency? -Joint Commission -Centers for Medicare & Medicaid Services (CMS) -Department of Health and Human Services (DHHS) -Occupational Safety and Health Administration (OSHA)

Pulse amplitude

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent? -Pulse amplitude -Pulse rate -Pulse rhythm -Pulse deficit

skin turgor

A nurse performing an integumentary inspection on a client gently pinches the skin under the clavicle. This nurse is assessing: -skin texture. -skin turgor. -skin vascularity. -skin moisture.

Comprehensive assessment

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?

otoscope

A nurse practitioner is preparing to examine a child with a suspected otitis media. Which instrument will be required? -sphygmomanometer -otoscope -pen light -ophthalmoscope

completing an incident report describing this near miss

A nurse prepared a client's medication, brought it to the client's bedside and then realized at the last minute that the medication was for another client of similar age and appearance. Follow-up to this event should include: -a suspension for the nurse, pending the completion of remedial education. -revising the procedures by which medications are distributed on the unit. -documenting this latent error and reporting it to relevant state agencies. -completing an incident report describing this near miss.

stretching a tape measure around the largest diameter and making guide marks on the skin

A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed? -measuring length and width of abdomen and documenting the anterior and posterior diameter -lying the client supine while percussing across the abdomen for dullness and marking the location -stretching a tape measure around the largest diameter and making guide marks on the skin -measuring from the top of the pubic bone to the top of the umbilicus and marking the height

Dull

A nurse uses percussion to assess a client's liver. What is the normal tone that should be heard in this situation? -Flat -Resonance -Tympany -Dull

Face the direction of movement

A nurse uses proper body mechanics to move a client up in bed. Which action is a guideline for using these techniques properly? -Keep body weight higher than center of gravity. -Face the direction of movement. -Twist body at the waist when lifting. -Keep feet together to provide a base of support.

highly active

A nurse wearing a Fitbit averages taking 14,000 steps daily when working a 12-hour shift, 3 days weekly. During a physical assessment, how will this nurse describe this activity level to the employee health nurse? -somewhat active -active -low active -highly active

Wash hands thoroughly and then wear sterile gloves

A nurse who has finished cleansing and dressing the wound of a young client now needs to change the dressings of a client in the burn unit. Which action should the nurse perform, keeping in mind the importance of asepsis and client comfort? -Avoid using alcohol-based hand sanitizers to protect skin integrity. -Wear gloves made of polyvinyl chloride. -Wash hands thoroughly and then wear sterile gloves. -Avoid washing hands with an antiseptic cleansing agent.

the reprimand has been deemed appropriate and relevant to the nurse's actions

A nurse who is a recent graduate has been formally reprimanded after administering a medication to the wrong client. This reprimand would be considered to be consistent with a just culture if: -the needs of the client were prioritized over the needs of the nurse. -the reprimand was legally documented. -the reprimand has been deemed appropriate and relevant to the nurse's actions. -the nurse received ample support from colleagues during the discipline process.

Collect data that are helpful when planning and delivering care

A nurse who provides care on a postsurgical unit is expecting 3 clients to be admitted to the unit from postanesthetic recovery within a short time span. The admission assessment document that is used on the unit is extensive and requires a significant amount of time to complete. Which principle should guide the nurse's assessments? -Delegate some assessments to unlicensed assistive personnel (UAP). -Enlist another nurse to do the documentation while the nurse performs the assessments. -Collect data that are helpful when planning and delivering care. -Collect as much client information as possible within the time available.

Snellen chart

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision? -Stethoscope -Snellen chart -Otoscope -Ophthalmoscope

Neutrophils, Eosinophils, Basophils

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply. -Neutrophils -Monocytes -Eosinophils -T-Lymphocytes -Basophils

"My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious."

A nursing student is performing an assessment on a client. Which of the following would the student record as subjective data? Select all that apply. -BP: 120/78 -"I am so afraid of what my diagnosis is." -"I am always anxious." -Weight: 132 pounds (60 kg) -"My leg hurts when I move."

"Help me understand your thoughts about vaccinations."

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response? -"Vaccinations prevent disease." -"Help me understand your thoughts about vaccinations." -"Has your child received any previous vaccinations?" -"Transmission of certain diseases is halted with vaccination."

False

A person's core body temperature is highest in the early morning and lowest in the late afternoon. False True

helps to determine prescribed antibiotic therapy

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason? -helps in reducing proliferation of multidrug-resistant organisms -permits selection of antibiotic concentration -helps to determine prescribed antibiotic therapy -narrows the therapeutic range to avoid prolonged use

interruptions to nurses who are in the process of preparing medications. nurses' having to provide care for large numbers of clients. nurse fatigue and caring for clients who have heavy care needs. the incidence of emergencies and urgent situations on the unit

A safety audit is being conducted on a hospital unit and the factors that have contributed to medication errors on the unit are being explored. What are factors that are known to underlie medication errors? Select all that apply. -nurse fatigue and caring for clients who have heavy care needs -nurses' having to provide care for large numbers of clients -the use of scheduled medications rather than p.r.n. (as needed) medications -the incidence of emergencies and urgent situations on the unit -interruptions to nurses who are in the process of preparing medications

diphtheria

A serious infection of the nose and throat that's easily preventable by a vaccine.

Normal body temperature

A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate? -Normal body temperature -Decreased body temperature -Increased body temperature -Fluctuating body temperature

Ask the instructor or a staff nurse to take the pulse

A student takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next? -Discuss this finding during postconference with other students. -Ask the instructor or a staff nurse to take the pulse. -Wait 4 hours and take the client's pulse again. -Record the pulse rate on the appropriate vital signs sheet in the chart.

Decreased cardiac output

A weak, thready pulse found after the nurse palpates peripheral pulses may indicate which condition? -Inflammation of a vein -Decreased cardiac output -Hypertension and circulatory overload -Impaired circulation

10,000

A white blood cell count of over _____/mL could indicate the presence of infection; this requires the nurse to intervene. All other findings are normal.

The blood pressure increases

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? -The blood pressure decreases. -The blood pressure increases. -The blood pressure does not change. -The blood pressure is erratic.

The blood pressure increases

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? -The blood pressure increases. -The blood pressure does not change. -The blood pressure is erratic. -The blood pressure decreases.

"Is there anything else we should know in order to care for you better?"

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? -"What are your expectations from us and from yourself in your care?" -"Is there anything else we should know in order to care for you better?" -"What do you envision for your care while you're here at the facility?" -"What practices have you found especially helpful in other settings?"

decreased cellular immunity

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify: -increased humoral immunity response. -decreased cellular immunity. -increased effectiveness of phagocytosis. -decreased susceptibility to infection.

communicable period

After explaining to students about the progression of infection, an instructor determines that the education was successful when the students identify which period as the time during which a disease can be passed from one person to another? -prodromal phase -active phase -incubation period -communicable period

Objective

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data? -Subjective -Unreliable -Physical -Objective

Objective

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data? -Subjective -Physical -Objective -Unreliable

The client claims her mobility and independence have declined in recent years

After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment? -The results of the client's bone scan indicate decreased bone density. -The client's serum calcium levels are below the reference range. -The client demonstrates an unsteady gait and spinal kyphosis. -The client claims her mobility and independence have declined in recent years.

124

After taking vital signs, the nurse writes down findings as T = 98.6 (37), P = 66, R = 18, BP = 124/82. Which number represents the systolic blood pressure? -66 -124 -82 -98.6 (37)

Eosinophils

After teaching a group of nursing students about the function of the various white blood cells, the instructor determines that the teaching was successful when the students identify which cell as being involved with allergic reactions? -Basophils -Monocytes -Eosinophils -Neutrophils

diligent handwashing practices

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? -reduced length of stay for MRSA-positive clients -prophylactic antibiotic therapy for MRSA-negative clients -diligent handwashing practices -constant use of gloves when on the unit

ensure that there is adequate lighting throughout the facility

An assault on a nurse by a client's family member has prompted a reevaluation of safety practices at a hospital. In order to reduce the risk of violence against nurses and other staff members, the hospital should: -mandate that nurses must always work in pairs on night shifts. -limit the number of visitors that can be on a unit at any given time. -ensure that there is adequate lighting throughout the facility. -teach all staff members about the correct use of restraints.

dry cracked lips, non-elastic turgor with prolonged tenting

An elderly man is brought to the emergency department with extreme dehydration. What would the nurse expect to see during the physical exam? (Select all that apply.) -smooth mucous membranes -capillary refill of 2 seconds -white patches on the mucous membranes -non-elastic turgor with prolonged tenting -dry cracked lips

collaborate with the nurse to identify any supplementary education that would be beneficial

An experienced nurse has a reputation for being conscientious and caring, so the nurse is shocked and embarrassed to have committed a medication error for the first time in her career. The nurse's supervisor should use what approach when responding to this event? -Temporarily assign the nurse a mentor so that her confidence can be reestablished. -Reassure the nurse that future errors are highly unlikely, given her strong work history. -Collaborate with the nurse to identify any supplementary education that would be beneficial. -Allow the nurse to follow up the event independently, knowing that she possesses the necessary knowledge and experience.

otitis media

An infection of the air-filled space behind the eardrum (the middle ear)

Explain to the client how the nurse will assist her

An obstetrics nurse is preparing to help a client up from her bed and to the bathroom 3 hours after the woman gave birth. Which action should the nurse perform first? -Explain to the client how the nurse will assist her. -Have the client stand for 30 seconds prior to walking. -Position a walker in front of the client to provide stability. -Enlist the assistance of another nurse or the physiotherapist.

Focused assessment

An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? -Initial assessment -Focused assessment -Time-lapse assessment -Emergency assessment

Recommended changes are consistently implemented at the point of care

Analysis is being conducted of a sentinel event that result in injury to a client. When putting forward recommendations to prevent future similar events, the safety committee should prioritize which of the following? -Proposed changes are based on current peer-reviewed evidence and clinical expertise. -The role of nurses in promoting overall safety in the hospital is acknowledged. -Recommended changes are consistently implemented at the point of care. -Changes in practice are reflective of clients' and families' preferences.

giving an overview of a new brand of needleless syringe that will be introduced in the unit

As part of a broader safety campaign, huddles are being introduced on a hospital unit. What will be the most appropriate use of this communication strategy? -brainstorming ideas for revising the scheduling system that is used for nurses' shifts -evaluating the overall safety practices that are used on the unit -giving an overview of a new brand of needleless syringe that will be introduced in the unit -reflecting on the care team's response to a cardiac arrest that took place on the unit

reduction in muscle cell size

Assessment of a client who is bedridden due to hip fracture reveals atrophy of the leg muscles due to immobility. The nurse demonstrates understanding of muscle atrophy by identifying what as a characteristic? -deposition of denser fibrotic tissue -less-pliable fibrotic tissue -reduction in muscle cell size -progressive shortening of muscle

Greater than 40.5°C

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely: -Above 38.2°C -Between 37.1°C and 38.2°C -Between 35°C and 36.8°C -Greater than 40.5°C

By 9 a.m. to ensure early administration of antibiotics

At 8:30 a.m., the client is admitted to the floor from the clinic with an infected spider bite wound. When administering the antibiotic, choose the time that infusion should be done following the severe sepsis resuscitation protocol. -At 12 noon to accommodate specimen collection from the wound and blood -By 9 a.m. to ensure early administration of antibiotics -At 10 a.m. when admission assessment is completed -By 11 a.m. when the pharmacy is able to send the medication to the floor

auscultation of short, high-pitched popping sounds during inspiration

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment? -percussion of loud, hollow sounds over the lateral lung fields -auscultation of short, high-pitched popping sounds during inspiration -an anteroposterior to lateral ratio of 1:2 -palpation of tactile fremitus over the posterior thorax

full-body sling lift

Clients who are unable to bear partial weight, full weight, or who are uncooperative should be transferred using a?

visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound

Common cardiovascular findings include

Don another pair of sterile gloves

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure? -Complete a sentinel event report. -Don another pair of sterile gloves. -No action is needed. -Notify the primary care provider.

xerostomia

Dry mouth

constriction of the pupils

During a physical exam, the nurse assesses a client's eyes for the accommodation response. When looking at a near object, what would the nurse observe for? -a consensual light reflex -constriction of the pupils -convergence of the eyes -conjugate movement of the eyes

Prodromal period

During an interaction with a client who is HIV-positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, and aches and pains. The nurse interprets these findings as reflecting which stage of the communicable period? -Incubation period -Prodromal period -Acute phase of illness -Convalescent period

inspect the sclera and mucous membranes

During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action? -Assess oxygen saturation level. -Observe for cyanosis or eccymosis. -Auscultate the lungs and abdomen. -Inspect the sclera and mucous membranes.

inversion and eversion of the ankle

During range-of-motion exercises, the nurse turns the sole of a client's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions? -dorsiflexion and plantar flexion of the ankle -internal and external rotation of the ankle -inversion and eversion of the ankle -flexion and extension of the ankle

Stand behind the client and palpate the sides of the trachea

During the admission assessment of a new client, the nurse is preparing to assess the client's thyroid gland. How should the nurse perform this assessment? -Auscultate over the client's trachea while asking the client to hold his breath. -Lightly percuss slightly off midline over the client's trachea. -Observe the midline of the client's neck while asking him to bear down. -Stand behind the client and palpate the sides of the trachea.

body systems

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to: -functional health patterns. -human needs. -body systems. -human response patterns.

Ask the client if it is okay to interview her husband for the answers to the interview questions

During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? -Ask the client if it is okay to interview her husband for the answers to the interview questions. -Ask the client's husband to come in and answer the interview questions. -Ask the client to wake up and try to answer the interview questions. -Wait until the next day to obtain the answers to the interview questions.

helps prevent overlooking some aspect of data collection reduces the number of position changes required of the client takes less time because the nurse doesn't have to constantly move around the client

During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply. -examines the same areas of the body several times before the assessment is complete -reduces the number of position changes required of the client -helps prevent overlooking some aspect of data collection -makes the problem easily identifiable because the findings tend to be clustered -takes less time because the nurse doesn't have to constantly move around the client

S3 heart sounds, Bruits

During the physical examination of a client, the nurse uses the bell of the stethoscope to identify which sounds? Select all that apply. -Bowel sounds -Breath sounds -S1 heart sounds -S3 heart sounds -Bruits

hyperalgesia

Enhanced sensation of pain produced by a noxious stimulus

allodynia

Enhanced sensation of pain produced by an innocuous stimulus, such as a light touch

Data are collected regarding the health perception/health management of the client. The perception of the major roles and responsibilities in the client's life is explored. Elimination, activity, sleep, and sexuality are components of the assessment and data collection

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health pattern model. Which statements reflect the focus of this model? Select all that apply. -The major body systems are assessed and data are collected. -The perception of the major roles and responsibilities in the client's life is explored. -Elimination, activity, sleep, and sexuality are components of the assessment and data collection. -Data are clustered or organized according to a hierarchy of basic human needs. -Data are collected regarding the health perception/health management of the client. -Data related to human response patterns are collected and organized.

faint that it can be heard only with great effort

Following auscultation of a client's heart, the nurse documents A grade I murmur. The characteristics of this type of murmur are:

faint murmur but one that can be easily detected

Following auscultation of a client's heart, the nurse documents A grade II murmur. The characteristics of this type of murmur are

very loud murmur that is usually associated with a thrill sound

Following auscultation of a client's heart, the nurse documents A grade IV murmur. The characteristics of this type of murmur are

an extremely loud murmur

Following auscultation of a client's heart, the nurse documents A grade V murmur. The characteristics of this type of murmur are

exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin

Following auscultation of a client's heart, the nurse documents A grade VI murmur. The characteristics of this type of murmur are

moderately loud

Following auscultation of a client's heart, the nurse documents grade III murmur. The characteristics of this type of murmur are: -faint; can be easily detected. -very loud, usually associated with a thrill sound. -extremely loud. -moderately loud.

the sound lateralizes to the unaffected ear

For a client with sensorineural loss What finding would the nurse expect to assess in this client.

an incontinent client in a nursing home who has diarrhea

For which client would the use of standard precautions alone be appropriate? -a client with diphtheria who needs p.m. care -a client with TB who needs medications administered -an incontinent client in a nursing home who has diarrhea -a child with chickenpox who is treated in the emergency room

"Client states, 'I don't see the point in trying anymore.'"

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation? -"Client states, 'I don't see the point in trying anymore.'" -"Client is demonstrating signs and symptoms of depression." -"Client states that his rehabilitation will be unsuccessful." -"Client makes statements indicating a loss of hope."

a loud tone heard normally over a gastric air bubble

How would you describe the percussion tone Tympany?

a harsh, inspiratory sound that may be compared to crowing

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor? -respirations that require excessive effort -high-pitched musical sound -discontinuous popping sounds -a harsh, inspiratory sound that may be compared to crowing

0.3 to 2.6

Lactic acid, present in blood as lactate, is a byproduct of metabolism that is usually metabolized in the liver. Normal levels are _ to _ mmol/L

shortly after the drug is given

Peak levels or the highest level of drug concentration are obtained when?

Peripheral vascular disease

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem? -Coronary artery disease -Pulmonary embolism -Chronic obstructive pulmonary disease (COPD) -Peripheral vascular disease

The skin of a client who has liver failure has a yellowish tint.

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data? -The skin of a client who has liver failure has a yellowish tint. -A client receiving chemotherapy reports nausea. -A client with inner ear infections reports dizziness. -A client states that she is feeling very anxious about her tests.

Nursing assessments focus on the client's responses to health problems. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. An initial assessment establishes a complete database for problem solving and care planning.

Nurses perform assessments on clients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? Select all that apply. -An initial assessment establishes a complete database for problem solving and care planning. -Nursing assessments focus on the client's responses to health problems. -The findings from a nursing assessment may contribute to the identification of a medical diagnosis. -The focus of a nursing assessment is on actual, not potential, health problems. -Nursing assessments duplicate medical assessments. -Nursing assessments target data pointing to pathologic conditions.

Color, moisture, and temperature of the skin

Of the following data, what type would be collected during a physical assessment? -Foods eaten that cause nausea -Color, moisture, and temperature of the skin -Type, amount, and duration of pain -Specific allergies resulting in itching

gingiva

Oral mucosa

The dorsum

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? -The palm -The fingertips -The dorsum -The knuckles

Pleuritis

Pleural friction rub is heard in cases of?

3+

Pulses that are increased and full volume are graded as

2+

Pulses that are normal and not easily obliterated are graded as

a normal lung

Resonance is a loud, hollow, low-pitched sound heard over

paradoxical blood pressure

Significant decrease in systolic blood pressure with inspiration

confusion

Sodium deficiency in elderly causes what?

asks the client to describe symptoms

The nurse is interviewing a client who is reporting chills, fever, malaise, and cough. During the working phase of the client interview, the nurse: -arranges for a private location. -introduces self to client. -asks the client to describe symptoms. -summarizes the key points of the interview.

newspaper tests

The Jaeger card is used to test near vision. what other test is used to test this?

bell

The ______ of the stethoscope is used to detect low-pitched sounds such as abnormal heart sounds (S3 or S4) and bruits

ophthalmoscope

The _______ is used to visualize the internal structures of the eye

diaphragm

The _______ of the stethoscope is used to detect high-pitched sounds such as breath sounds, normal heart sounds (S1, S2), and bowel sounds.

Auscultation of a bruit

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider? -Percussion of dull sounds over the right upper quadrant -Auscultation of a bruit -Auscultation of peristalsis sounds -Percussion of tympanic sounds over the intestines

To simulate the distance between people during social interaction

The nurse is assessing a client's hearing acuity. During the voice test, the nurse stands approximately 2 feet behind and to the side of the client. Why should the nurse take this position during the voice test? -to simulate the distance between people during social interaction -To assess the client's ability to discriminate sound -to deliver a high-pitched sound toward the tested ear -to facilitate sound conduction to the tested ear only

the client with cancer and with neutropenic precaution

The charge nurse is working on client assignments for the incoming shift. A client with methicillin-resistant Staphylococcus aureus (MRSA) is assigned to a nurse. Which type of client should the charge nurse avoid assigning to the incoming nurse? -the client with cancer and with neutropenic precaution -the client who has a urinary catheter -the postoperative client with a large abdominal wound -the client on air-borne precaution

Use a wide stance and lift with the large leg muscles, Face the direction of the activity he is performing, Adjust the height of the work area

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. -Use a wide stance and lift with the large leg muscles. -Hold his breath only when lifting heavy objects. -Face the direction of the activity he is performing. -Adjust the height of the work area.

Contact

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission? -Airborne -Vehicle -Droplet -Contact

"This antibiotic is the best choice since the causative organism is not known."

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug? -"Pneumonia is usually caused by multiple organisms." -"This antibiotic is the best choice since the causative organism is not known." -"Drug resistance can develop when the wrong antibiotic is used for pneumonia." -"This antibiotic causes fewer side effects than a narrow spectrum antibiotic."

on top of the foot

The nurse is assessing a client's pedal pulse. The nurse would palpate at which area? -on top of the foot -behind the knee -level of the fifth intercostal space -behind bony protuberance of the inner ankle

The client's nurse committed an active error by raising all four of the side rails.

The manager of a geriatric medicine unit is reviewing some of the incident reports that have been filed over the past several months. One report describes an event where a nurse raised all four side rails of a confused client's bed, causing the client to fall when he tried to climb over them to go to the restroom. Which of the following statements about this incident is most accurate? -The root cause of the incident was the client's decreased cognition. -The root cause of the incident was the nurse's flawed decision-making. -The location of the restroom relative to the client's bed was a latent error. -The client's nurse committed an active error by raising all four of the side rails.

"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin."

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? -"Alcohol based hand rub provides the greatest reduction in microbial counts on the skin." -"We only wash our hands when they are visibly soiled." -"Washing the hands with soap and water is not necessary." -"I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene."

raising the height of the bed to the waist level prior to moving the client

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? -placing the client in good alignment with joints slightly flexed -raising the height of the bed to the waist level prior to moving the client -replacing pillows and positioning devices -turning the client as a complete unit to avoid twisting the spine

"It is easier to twist my back when moving objects from side to side."

The nurse has completed proper body mechanic education for a group of unlicensed assistive personnel (UAP). Which UAP statement requires the nurse to intervene? -"It is easier to twist my back when moving objects from side to side." -"We should report to our manager if items we need are located on shelves that are too high to reach." -"When moving a client, we need to plan ahead for the distance we will be going." -"I will ask another UAP to assist with lifting heavy loads."

Measure the client's oral temperature

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? -Measure the client's oral temperature. -Obtain an order for blood cultures. -Give the client a clean gown and warm blankets. -Ask a colleague for assistance.

The client's weak pulses may be indicative of cardiovascular disease

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted? -The client's weak pulses may be indicative of cardiovascular disease -The client has normal peripheral pulses. -The client shows no signs of a circulatory health problem. -The client has increased radial pulses that may result from hypertension.

Subjective Objective

The nurse identifies which of the following as types of data that are used when performing an assessment? Select all that apply. -Subjective -Intuition -Objective -Hunches -Critical thinking

All clients must ambulate as early as possible to avoid infection

The nurse instructor is discussing the relation of early ambulation and infection control. Which response from the student indicates the need for further explanation? -All clients must ambulate as early as possible to avoid infection. -Aerobic exercises may prevent respiratory infections. -Encourage as much activity as the client can tolerate without fatigue. -If unable to ambulate, turn the client in bed at least every 2 hours.

Wheezing on auscultation

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse? -Crying with burning pain -Heart rate of 100 -Erythema at sting site -Wheezing on auscultation

nits from a lice infestation

The nurse is assessing a child brought to the clinic with severe itching of the scalp and white patches on the hair follicles. What would the nurse look for when beginning the examination? -seborrheic dermatitis -alopecia -nits from a lice infestation -tinea capitis

Supplement the client's information by speaking with family or friends

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? -Obtain the client's records from admissions to other institutions. -Supplement the client's information by speaking with family or friends. -Perform the assessment in several short episodes rather than at one sitting. -Limit the assessment to objective data.

The tympanic membrane is translucent, shiny, and gray

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? -The ear canal is rough and pinkish. -The ear canal is smooth and white. -The tympanic membrane is reddish. -The tympanic membrane is translucent, shiny, and gray.

2+ pitting edema

The nurse is assessing the legs of a client and notes fairly normal contour with a 4 mm indentation when pressing on the shin and calf of each leg. How should the nurse interpret these findings? -1+ pitting edema -Brawny edema -trace edema -2+ pitting edema

contact precautions

The nurse is assisting a client with a history of vancomycin resistant enterococcus (VRE). What precaution should the nurse implement? -standard precautions -contact precautions -droplet precautions -airborne precautions

Quality

The nurse is auscultating a client's abdomen and is able to hear gurgling sounds. When documenting this finding, which characteristic of sound is noted? -Quality -Texture -Turgor -Rhythm

Ask the client to cough and auscultate the anterior chest again

The nurse is auscultating the anterior chest of a client and hears gurgles. What is the nurse's appropriate action? -Document the findings. -Ask the client to cough and auscultate the anterior chest again. -Notify the healthcare provider. -Ask the client if they have any difficulty breathing.

142 beats per minute

The nurse is calculating the maximum heart rate for a 70-year-old client. Which accurately reflects the client's maximum heart rate? -142 beats per minute -175 beats per minute -125 beats per minute -200 beats per minute

immobilizer

The nurse is caring for a 21-year-old professional ballerina who sustained a knee sprain while dancing. Which splint will the nurse prepare to apply? -inflatable -immobilizer -traction -molded

transfer belt

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? -transfer belt -roller sheet -transfer boards -mechanical lift

Apply a non-particulate (N-95) respirator when entering the room

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse? -Apply a non-particulate (N-95) respirator when entering the room. -Wear a mask with face shield during invasive procedures. -Have the client wear a mask during care. -Wear a protective gown and gloves with any direct contact.

Apply elastic stocking

The nurse is caring for a client needs to use a tilt table to move from supine to standing. Which intervention will the nurse perform first? -Apply elastic stocking. -Tilt in increments of 15 to 30 degrees. -Position feet against foot rest. -Strap client securely onto table.

no signs or symptoms

The nurse is caring for a client that has a colonized infection. What assessment data does the nurse anticipate collecting? -alternating periods of nausea and vomiting -fever of 100° F (37.78° C) -reports of feeling well because the infection has resolved -no signs or symptoms

noncommunicable disease

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition? -contagious disease -noncommunicable disease -infectious disease -communicable disease

healthcare associated infection (HCAI)

The nurse is caring for a client who developed a urinary tract infection while hospitalized. How will the nurse document this condition? -infectious disease -community acquired infection -contagious disease -healthcare associated infection (HCAI)

swelling within fascia that does not expand

The nurse is caring for a client who had a leg cast applied 24 hours earlier, and has returned to the emergency department (ED) reporting pain of "9" on a 1-10 scale. Which additional assessment finding does the nurse anticipate? -swelling within fascia that does not expand -capillary refill in toes of 2-3 seconds -confusion -fever of 100 degrees F (37.77 degrees Celsius)

Provide fracture pan as needed

The nurse is caring for a client who has a hip spica. Which nursing intervention is appropriate? -Prepare for Foley catheterization. -Delegate ambulation to bathroom to UAP. -Order bedside commode. -Provide fracture pan as needed.

Remove fresh fruit from the room

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? -Allow many family members to visit at once. -No special precautions are required. -Deliver flowers and balloons to the room. -Remove fresh fruit from the room.

skin

The nurse is caring for a client who has been placed into Buck's traction. Which type of traction intervention does the nurse document that this is? -Russell's -manual -skin -skeletal

four-point

The nurse is caring for a client who has generalized weakness and requires crutches to ambulate. Which crutch-walking gait will the nurse teach? -swing-through -'three-point partial weight-bearing -four-point -two-point

"I can leave my room any time I want as long as I wear a mask."

The nurse is caring for a client who requires droplet precautions. Which statement made by the client would indicate further teaching is required? -"I can leave my room any time I want as long as I wear a mask." -"I will tell my visitors to keep their distance from me." -"Any staff that enters my room will be wearing personal protective equipment (PPE)." -"My personal belongings should remain in the room until I am discharged."

Contact the healthcare provider

The nurse is caring for a client who sustained an ankle fracture in a skiing accident this morning. After surgery, the leg and ankle were casted. At 1500, the client reports pain of "5" on a 1-10 scale. At 1700, pain has increased to a "7" despite pain control interventions. At 1900, the client reports pain of a "9" even following opioid medication administration. Which nursing intervention is appropriate? -Contact the healthcare provider. -Activate the Rapid Response Team. -Utilize prn doses of pain control medication. -Reassure the client that increasing pain is expected after surgery.

"The healthcare provider will remove the cast by cutting it with a cast cutter.", "The cast cutter looks like a circular saw.", "I will stay with you while the cast is removed."

The nurse is caring for a client whose cast will be removed later in the day. What information will the nurse provide? (Select all that apply.) -"I will stay with you while the cast is removed." -"You will not be able to put lotion on your skin for several weeks." -"The healthcare provider will remove the cast by cutting it with a cast cutter." -"The cast cutter looks like a circular saw." -"If there is residual dead skin on your arm, we can scrub it off."

Three-point partial weight-bearing

The nurse is caring for a client with a previous knee injury that is healing. Which crutch-walking gait will the nurse teach? -Four-point -Three-point partial weight-bearing -Two-point -Swing-through

The client's heart rate is greater than 90 bpm

The nurse is caring for a client with a stage IV leg ulcer. The nurse is closely monitoring the client for sepsis. What would indicate that sepsis has occurred and that the physician should be notified immediately? -The client feels restless and hungry. -The client's respiratory rate is less than 20 breaths/min. -The client exhibits an increased urinary output. -The client's heart rate is greater than 90 bpm.

molded

The nurse is caring for a client with carpal tunnel syndrome. Which type of splint does the nurse anticipate will be ordered? -inflatable -immobilizer -molded -traction

Sims'

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? -supine -prone -Fowlers' -Sims'

Use a powered air purifying respirator (PAPR)

The nurse is caring for a client with tuberculosis who has been placed in airborne precautions. The nurse has not yet been fitted with an N95 respirator. Which nursing action is appropriate? -Use a powered air purifying respirator (PAPR). -Refuse to care for the client until fitted for an N95 respirator. -Use a mask when caring for the client. -Ask another nurse who has been fitted for an N95 respirator to assume care.

infectious disease, communicable disease, contagious disease

The nurse is caring for a pediatric client who became very ill after being in a day care where a number of other children are sick with the same condition. How will the nurse document this condition? (Select all that apply.) -noncommunicable disease -contagious disease -infectious disease -communicable disease -health care-associated infection (HCAI)

"Let's talk about how mobility can increase your independence."

The nurse is caring for an older adult client who has difficulty walking. The client states, "I hate that I can barely walk. I'm such a burden to my family." What is the appropriate nursing response? -"Let's talk about how mobility can increase your independence." -"Put that thought out of your mind, and let's focus on using a walker." -"I'm sure no one feels that way about you." -"Who told you that you are burden?"

contact

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin? -airborne -droplet -contact -none

the client who is 48-hours post-surgical procedure

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? -the client admitted with a rash who reports recent exposure to measles -the client placed in contact isolation who was admitted with a draining abdominal wound -the client who is 48-hours post-surgical procedure -the client admitted with diarrhea who tested positive for Escherichia coli (E.coli)

omission of pertinent data

The nurse is conducting a nursing assessment with a client who is unwilling to participate in the interview process. If the nurse makes a diagnostic error it would most likely be because of: -misinterpretation of data. -failure to validate the data. -omission of pertinent data. -failure to analyze the data.

Health status, Strengths, Health problems, Health risks

The nurse is conducting a nursing/health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply. -Health status -Health problems -Financial status -Health risks -Strengths

The client states that a mole on his forehead has become larger in recent months

The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which finding should the nurse document as an anomaly that may warrant follow-up? -Decreased skin turgor is evident when the skin is folded and then released. -There are some raised, brown areas on the backs of the client's hands. -Small, round, red spots are present on the client's forearms bilaterally. -The client states that a mole on his forehead has become larger in recent months.

Focus full attention on the client

The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview? -Focus on the computer so as not to make a mistake. -Focus full attention on the client. -Focus on interventions being planned for this client. -Focus on notes so as not to make the client uncomfortable.

Consider adding grab bars to shower or tub, Assess for adequate lighting so client can see clearly when walking, Replace rubber tips on cane as soon as they become worn or dirty.

The nurse is educating a client and family about home safety. Which teaching will the nurse include? (Select all that apply.) -Consider adding grab bars to shower or tub. -Assess for adequate lighting so client can see clearly when walking. -Place rugs over hard flooring to provide a buffer in case of falls. -Have client use steps to facilitate mobility. -Replace rubber tips on cane as soon as they become worn or dirty.

"Can you tell me what you mean when you say 'fuzzy'?"

The nurse is interviewing a client who was admitted to the acute care facility. During the interview, the client states, "Sometimes I get a bit fuzzy after I take my medicine." Which response by the nurse would be most appropriate? -"Can you tell me what you mean when you say 'fuzzy'?" -"Are you experiencing lightheadedness with the medication?" -"What medications are you taking currently?" -"That's not unusual. I've heard several clients tell me the same thing."

Palpable pulsation over the mitral area

The nurse is palpating a client's precordium. What is an expected clinical finding? -Palpable vibration over the right sternal border -Palpable pulsation over the mitral area -Palpable heave over the pulmonic area -Palpable thrill over the aortic area

Assess the client for dehydration

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? -Report the finding as a positive sign for cystic fibrosis. -Assess the client for cardiovascular disorders. -Document a normal skin finding on the client chart. -Assess the client for dehydration.

Validate the data

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next? -Validate the data. -Ignore the client's answer. -Chart the data. -Ignore the client's nonverbal behavior.

a pronounced lateral curvature of the spine

The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis? -an increased curve in the thoracic area -a pronounced lateral curvature of the spine -an exaggerated lumbar curve of the spine -a gentle concave and convex curve of the spine

scoliosis

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? -kyphosis -scoliosis -increased need for calcium and vitamin D -shifted center of gravity

decreased heart rate

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician? -presence of an S heart sound -decreased heart rate -sinus dysrhythmia that increases with inspiration and decreases with expiration -visible pulsation through a thin chest wall

coordinated movement of both eyes

The nurse is performing the positions test on a client following a head injury. Which assessment would the nurse interpret as a normal finding? -convergence of the eyes -coordinated movement of both eyes -nystagmus when looking in an upward position -limited movement in one eye when moving from superior to inferior position

shortness of breath after walking up five stairs

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? -joint stiffness after sitting for an hour -shortness of breath after walking up five stairs -a change in pulse from 80 to 84 after walking up 20 stairs -walking with a slow and uncoordinated movement

"I will keep walking even if I feel exhausted."

The nurse is preparing a client for a stress electrocardiogram. Which client statement requires further nursing teaching? -"I will wear a pulse oximeter to measure my level of oxygenation." -"The speed and incline of the treadmill will increase as the test goes on." -"You will monitor my heart rate and rhythm while I walk." -"I will keep walking even if I feel exhausted."

hand washing

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan? -hand washing -sterile technique -putting on gloves -signs of healing

sitting up with the elbow flexed, and forearm resting on the thigh, palm up

The nurse is preparing to assess a client's deep tendon reflexes. When evaluating the biceps reflex, the nurse would position the client in which manner? -lying supine with the knee slightly flexed and foot dorsiflexed -sitting up with the elbow flexed, and forearm resting on the thigh, palm up. -Sitting up with arm held across the chest, with the elbow flexed at a 90-degree angle. -sitting at the side of the exam table with legs hanging loosely over the side.

deep in the posterior sublingual pocket

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? -in the inferior buccal space on either side of the tongue -along either upper gum line adjacent to an incisor -superior to the tongue with the tip touching the hard palate -deep in the posterior sublingual pocket

Ask the client to read the print on a handheld Jaeger card

The nurse is preparing to assess near vison a client. How should the nurse proceed? -Perform a visual field examination. -Use the Snellen chart positioned at 20 feet. -Ask the client to read the print on a handheld Jaeger card. -Have the client track an object as it moves in each of six positions.

Ask the client to empty her bladder

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? -Warm the equipment. -Measure height and weight. -Ask the client to empty her bladder. -Place the client in a semi-Fowler's position.

allowing client to select time of day to ambulate

The nurse is preparing to help a client ambulate after hip surgery. Which nursing action promotes client autonomy? -washing hands before interacting with the client -placing gait belt onto client -allowing client to select time of day to ambulate -assisting client to put on supportive shoes

thrombus formation

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? -thrombus formation -pooling of secretions -oliguria -skeletal contractures

Have the client cover one eye with a hand or index card. The nurse should cover her own eye opposite the client's closed eye. The nurse holds one arm outstretched to one side equidistant from her and the client, and moves her fingers into the visual fields from various peripheral points

The nurse is testing the peripheral vision of a client. Which actions are recommended guidelines for this test? Select all that apply. -The nurse holds one arm outstretched to one side equidistant from her and the client, and moves her fingers into the visual fields from various peripheral points. -Have the client cover one eye with a hand or index card. -Ask the client to state when the fingers are first seen (nurse should see the fingers a second before the client). -The nurse asks the client to look directly at a predetermined spot on the wall behind her. -The nurse should cover her own eye opposite the client's closed eye. -Have the client stand or sit about 1 metre away.

Stop lifting the client and reassess him

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? -Enlist the help of another nurse to hold the client steady during the procedure. -Stop lifting the client and reassess him. -Administer a sedative to the client and try again when the sedative takes effect. -Reassure the client that the procedure will only take a few minutes.

Sterile field is kept above waist level

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct? -Maintain a 3-inch border around the sterile field. -Put on sterile gloves before opening sterile package. -Open sterile package towards the nurse to prevent reaching over. -Sterile field is kept above waist level.

Equipment is positioned to the side, 50 degrees away

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? -Equipment is positioned to the side, 50 degrees away. -Work is being carried out under sources of non-glare lighting. -Chairs have firm back support and allow the feet to touch the floor. -A small dolly is used to transport heavy items.

Palpation

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? -Auscultation -Palpation -Percussion -Inspection

Inspection Palpation Percussion Ausculation

The nursing instructor is demonstrating to the class how to perform a physical assessment. Which assessment technique should be demonstrated by the nursing instructor? Select all that apply. -Ausculation -Percussion -Palpation -Inspection -Documentation

Secretions

The nursing instructor is discussing mechanical and chemical defense mechanisms of the body that help prevent infection. The instructor tells the students that chemical defense mechanisms either destroy or incapacitate microorganisms with biologic substances that the body naturally produces. What is a chemical defense mechanism of the body? -Catecholamines -Secretions -Hormones -Corticosteroids

The nurse should show her name badge to the client so he can identify the nurse

The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction? -The nurse should show her name badge to the client so he can identify the nurse. -The nurse should introduce herself and give name and position. -The nurse should sit on eye level with the client. -The nurse should ask the client what name he would like to be called. -The nurse should verify the client's name.

"Both of your feet should rest on the floor."

The occupational nurse is teaching an administrative assistant about proper posture when sitting. Which teaching will the nurse include? -"Both of your feet should rest on the floor." -"Keep your knees bent, with the back of the knees against your chair." -"Cross your legs alternately throughout the day." -"Upper and lower thighs are your base of support."

Position a heavy load over the center of the feet when lifting, Bend the knee and keep the back straight when lifting, Push, pull, or roll objects whenever possible

The occupational nurse is teaching other nurses how to protect the back by using proper body mechanics. Which teaching will the nurse include? (Select all that apply.) -Position a heavy load over the center of the feet when lifting. -Hold heavy objects away from the body. -Keep the feet together when lifting. -Push, pull, or roll objects whenever possible. -Bend the knee and keep the back straight when lifting.

just before the 6 a.m. dose

The physician orders a serum trough drug level for a client who is receiving antibiotic therapy. The client is receiving the drug every 6 hours: at midnight, 6 a.m., noon and 6 p.m. The nurse anticipates that the specimen would be obtained: -at 6 p.m. -just before the 6 a.m. dose. -at 7 a.m. -immediately after the noon dose.

ecchymosis

The presence of purple patches on the skin, due to trauma to soft tissue, is documented as .

flushed

The skin of a client with fever and hypertension appears pink and is documented as

Monocytes

These are scavenger cells that dispose of cellular debris

vesicular sounds

These sounds are longer on inspiration than expiration, with no pause between them

bronchovesicular sounds

These sounds are medium-range sounds of equal length during inspiration and expiration, with no noticeable pause

bronchial sounds

These sounds are shorter on inspiration than expiration, with a pause between them

prodromal period

This period is characterized by nonspecific symptoms.

incubation

This period is the time between the pathogen's entrance and the appearance of symptoms.

incubation period

This period refers to the time between the pathogen's entrance into the host and the appearance of symptoms.

acute phase

This phase occurs when specific symptoms and often laboratory analysis can identify the disease

measuring and disseminating the hospital's HAI rate

Though evidence is not readily available, a rural hospital has a local reputation of having a high rate of healthcare-associated infections (HAIs). Which strategy is most likely to improve the institution's infection control practices? -adopting care bundles for clients with intravenous access -measuring and disseminating the hospital's HAI rate -providing interdisciplinary education around medication safety -arranging for an Occupational Safety and Health Administration (OSHA) audit

Wheezes

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? -Wheezes -Stertorous breathing -Fine crackles -Pleural friction rub

Ongoing partial assessment

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing? -Comprehensive assessment -Emergency assessment -Ongoing partial assessment -Focused assessment

The client's pulse rate is below 60 beats per minute

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? -The client's respiratory rate is less than 18 breaths per minute. -The client's systolic blood pressure is less than 100 mm Hg. -The client's pulse rate is below 60 beats per minute. -The client is unable to stay upright when blood pressure is checked.

Cardiac sinoatrial (SA) node

What anatomic site regulates the pulse rate and force? -Thermoregulatory center -Cardiac atria and valves -Cardiac sinoatrial (SA) node -Peripheral chemoreceptors

The nurse will first apply antiembolism stockings to prevent the pooling of blood in the extremities, which may trigger fainting. The client will then be transferred and strapped securely onto the table, feet will be placed against the foot rest, and the table will be tilted in 15 to 30 degree increments.

What are the steps a nurse will provide for caring for a client who needs to use a tilt table to move from supine to standing.

do not hear a hyperresonant sound in both ears.

What finding would the nurse expect to assess in Clients with conductive hearing loss

will hear the vibrations equally in both ears

What finding would the nurse expect to assess in People with normal hearing

If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field

What is a recommended guideline for maintaining a sterile field? -If a supply is missing, the nurse may leave the sterile field briefly to obtain it. -If the client touches the nurse's gloves during the procedure, the nurse may still proceed with the procedure. -When a portion of the sterile field becomes contaminated, the nurse should remove the contaminated objects and continue with the procedure. -If the client touches the sterile field, the nurse should discard the supplies and prepare a new sterile field.

oral: 37°C

What is an average normal temperature in Celsius for a healthy adult? -axillary: 37.5°C -oral: 37°C -tympanic: 34.4°C -rectal: 36.5°C

to identify actual and potential health problems

What is one purpose of documentation of the health assessment? -to expand nursing knowledge and skills -to identify the nurse's role in health care -to identify actual and potential health problems -to provide a basis for evidence-based nursing

to plan appropriate nursing care

What is the primary purpose of validation as a part of assessment? -to maintain effective relationships with coworkers -to plan appropriate nursing care -to establish an effective nurse-client communication -to identify data to be validated

50

What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg? -50 -214 -100 -1.6

Weber test

What test helps to determine the equality or disparity of bone-conducted sound.

Coughing

What would be considered a mechanical defense mechanism? -Clothing -Cast -Coughing -Sunscreen

Keep focused on the task or goals to ensure that needed data are obtained and goals are achieved. Observe the client's behavior, and listen attentively

Which action is taken during the maintenance phase of an interview? Select all that apply. -Keep focused on the task or goals to ensure that needed data are obtained and goals are achieved. -Observe the client's behavior, and listen attentively. -Review goal or task attainment. -Establish a verbal contract with the client, incorporating the goals of the interview. -The nurse assesses her own feelings or reactions to previous clients that might interfere with the nurse-client relationship.

Demonstrate adequate knowledge on infection control

Which client goal related to infection control is a priority? -Demonstrate use of good health practices. -Minimize infection exposure. -Participate in treatment regimens to prevent infection. -Demonstrate adequate knowledge on infection control.

a client recovering from a bone marrow transplant

Which client is most likely to require neutropenic precautions? -a client recovering from a bone marrow transplant -a client awaiting a liver transplant -a client diagnosed with tuberculosis -a client recovering from orthopedic surgery

an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

Which client presents the most significant risk factors for the development of Clostridium difficile infection? -an 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis -A client with renal failure who receives hemodialysis three times weekly -a 44-year-old client who is paralyzed and whose coccyx ulcer has required a skin graft -A 30-year-old client who has recently contracted human immunodeficiency virus (HIV) after engaging in high-risk sexual behavior

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit

Which client situation most likely warrants a time-lapse nursing assessment? -A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema. -An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. -The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. -A client is being admitted to a general medicine unit after spending several days in the intensive care unit.

an alert client after knee replacement surgery who is being assisted to ambulat

Which client would be an appropriate candidate to move by using a powered stand-assist device? -an alert client after knee replacement surgery who is being assisted to ambulate -a comatose client who is being taken for x-rays -a car accident victim with fractures in both legs who is being moved to another room -an obese client who has Alzheimer's disease and is being escorted to the shower room

client who requires considerable assistance with balance

Which client would benefit the most from the use of a walker to assist in ambulation? -client who needs permanent assistance when walking -client who needs brief, temporary assistance ambulating -client who has weakness on one side of the body -client who requires considerable assistance with balance

a client with low blood volume

Which client would the nurse consider at risk for low blood pressure? -a client with low blood volume -a client with high blood viscosity -a client with decreased elasticity of walls of arterioles -a client with a strong pumping action of blood into the arteries

client with gastric tube feeding, client with an indwelling catheter, client with an IV catheter

Which clients are at a heightened risk for infection? Select all that apply. -client with hypertension -client with an IV catheter -client with hypothermia -client with an indwelling catheter -client with gastric tube feeding

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels

Which describes diastolic blood pressure? -During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. -the flow of blood produced by contractions of the heart and the resistance to blood flow through the vessels -The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. -the blood pressure measured during ventricular contraction

A client has trouble reading an informed consent, but states he does not need glasses. An older adult client explains that the black and blue marks on his arms and legs are due to a fall.

Which example of client data needs to be validated? Select all that apply. -An older adult client explains that the black and blue marks on his arms and legs are due to a fall. -A nurse examining a client with a respiratory infection documents fever and chills. -A client in a nursing home states that she is unable to eat the food being served. -A pregnant client is experiencing contractions that are 2 minutes apart. -A client has trouble reading an informed consent, but states he does not need glasses.

Sweat

Which factors are identified as the body's defense against infection? -Interferon -Saliva -Acidic pH of the vagina -Peristalsis -Sweat

Collection, validation, communication of client data

Which group of terms best defines assessing in the nursing process? -Design a plan of care, implement nursing interventions -Problem-focused, time-lapsed, emergency-based -Nurse-focused, establishing nursing goals -Collection, validation, communication of client data

"Assessment data about the client should be collected continuously."

Which guideline should a nursing instructor provide to nursing students who are now responsible for assessing their clients? -"Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." -"Assess your client at least hourly if the client's vital signs are unstable, and every 2 hours if the vital signs are stable." -"Assessment data about the client should be collected continuously." -"Assessment data should be collected prior to the physician rounding on the unit."

Inspiration is a passive process

Which is not true of respiration? -External respiration is the process of taking oxygen into, and eliminating carbon dioxide from, the body. -Inspiration is a passive process. -Normal tidal volume is 500 mL/minute. -During inspiration, the pressure in the airway becomes negative and air flows inward.

Asking the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours."

Which items reflect the assessment phase of the nursing process? Select all that apply. -The nurse assists the client with coughing and deep breathing every hour. -The client's abdomen is firm and distended with hypoactive bowel sounds. -Asking the client, "How would you rate your pain?" -The nurse and the client determine a tolerable pain level. -The client states, "I rarely sleep more than 6 hours."

Gabapentin

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? -Lorazepam -Morphine -Gabapentin -Hydromorphone

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)? -delivering a meal tray to a VRE-positive client without first donning gloves and a gown -Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair -sending a VRE-positive client to the radiology department for a chest X-ray without a face mask -removing the staples from a VRE-positive, postoperative client's incision without prior handwashing

airborne precautions, droplet precautions, contact precautions

Which of the following are names of the transmission-based precautions defined by the Centers for Disease Control (CDC)? Select all that apply. -droplet precautions -airborne precautions -microbial precautions -contact precautions -respiratory precautions -body fluid precautions

Temperature, turgor, moisture

Which of the following can a nurse assess by palpation? -Temperature, turgor, moisture -Vision, hearing, cranial nerves -Heart sounds, lung sounds, blood pressure -Tissue density, gait, reflexes

Carotid

Which peripheral pulse site is generally used in emergency situations? -Carotid -Apical -Radial -Temporal

gown and gloves

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile? -gown and gloves -respirator mask and gown -goggles and gloves -mask and shoe covers

Tuning fork

Which piece of equipment is used to perform the Weber test and Rinne test? -Reflex hammer -Laryngeal mirror -Cotton-tipped applicator -Tuning fork

Gloves

Which piece of personal protective equipment (PPE) should be removed first? -Gown -Goggles -Gloves -Respirator

Respect for client Caring Professionalism Competence

Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply. -Respect for client -Caring -Number of years in profession -Professionalism -Competence

oral

Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? -Tympanic -Oral -Rectal -Axillary

The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair The vascular and cellular stages are the main components of the inflammatory process, and these physiologic processes are responsible for the appearance of the cardinal signs.

Which statement accurately describes a component of the inflammatory response? select all that apply -The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. -The antigen-antibody reaction, also known as humoral immunity, is one component of the overall inflammatory response. -The inflammatory response involves specific body responses to an invading foreign protein, such as bacteria, or in some cases, to the body's own proteins. -Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair. -The vascular and cellular stages are the main components of the inflammatory process, and these physiologic processes are responsible for the appearance of the cardinal signs.

S3 is considered normal in children and young adults and abnormal in middle-age and older adults.

Which statement accurately represents a characteristic of the third or fourth heart sound? -S3 is best heard with the stethoscope bell at the mitral area, with the client lying on the right side. -S4 is considered normal in children and adults, but abnormal in older adults. -S3 is considered normal in children and young adults and abnormal in middle-age and older adults. -S4 is the fourth heart sound, represented by "lub-dub-dee."

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse? -Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume. -Stimulation of the parasympathetic nervous system results in an increase in the pulse rate. -The sympathetic nervous system is the dominant activation during resting states. -Stimulation of the sympathetic nervous system results in a decrease in the pulse rate.

"If stump socks get holes in them, purchase new ones."

Which teaching will the nurse include when educating a client with a below-the-knee amputation about stump socks? -"You should only wear cotton stump socks." -"Tube socks are recommended to go over the stump." -"If stump socks get holes in them, purchase new ones." -"Be certain to only wear one sock over the stump at a time."

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction

Which technique should the nurse use to assess the pupillary light reflex on a client? -Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. -Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye. -Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. -Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction.

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction

Which technique should the nurse use to assess the pupillary light reflex on a client? -Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye. -Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. -Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. -Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

Palpate the pulse for 1 minute

Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation? -Palpate the pulse for 2 minutes. -Palpate the pulse for 10 seconds and multiple by 6. -Palpate the pulse for 15 seconds and multiply by 4. -Palpate the pulse for 1 minute.

Pyrexia

Which term indicates a potentially serious client condition? -Afebrile -Pyrexia -Pulse pressure -Eupnea

Focused assessment

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? -Emergency assessment -Focused assessment -Time-lapse assessment -Initial assessment

Moisture in air passages

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? -A narrowing of the upper airway -Narrowed small air passages -Moisture in air passages -Air in the lungs

a crack in the skin, especially in or near a mucous membrane

While assessing the characteristics of the skin of the client, the nurse observes a mouth slit at the aperture of the mouth. The nurse documents this finding as a fissure. What is a fissure? -an open, crater-like area on the skin -a crack in the skin, especially in or near a mucous membrane -an area of the skin that has been rubbed away by friction -a mark left on the skin by the healing of a wound or lesion

"The culture will let us know if you have an antibiotic-resistant bacterium."

While collecting a nasal culture for a client who was admitted from a skilled nursing facility, the client asks, "Why are you doing this?" What is the best response by the nurse? -"This will let us know what antibiotic you will need." -"The culture will let us know if you have an antibiotic-resistant bacterium." -"The culture will give us a baseline, in case you develop symptoms of an infection." -"It is policy for all clients from skilled nursing facility to be cultured."

Bronchovesicular

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? -Bronchial -Vesicular -Adventitious -Bronchovesicular

Bronchovesicular

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? -Bronchovesicular -Adventitious -Bronchial -Vesicular

Validate the questionable data

While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first? -Validate the questionable data. -Inform the client that the data are not correct. -Disregard the questionable data. -Inform the physician of the questionable data.

palpation

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique? -Palpation -Auscultation -Percussion -Inspection

lateral deviation of the thoracic spine

While performing a physical examination on a client, the nurse observes that the client has scoliosis based on: -concave curvature of the lumbar spine. -convex curvature of the thoracic spine. -concave curvature of the cervical spine. -lateral deviation of the thoracic spine.

covering arm with stockinette

While preparing a client with a forearm fracture for casting, the nurse washes and dries the skin. Which nursing action is next? -covering arm with stockinette -applying arm sling -providing home care teaching -preparing cast material

Auscultate lung sounds. Check site of wound. Check IV site for infiltration. Review how compliant the client has been with ambulation

While the nurse is conducting morning rounds, the nurse notices that the client's temperature has gradually increased for the past 3 days. Which assessment should the nurse do next? select all that apply -Check IV site for infiltration. -Check site of wound. -Call the laboratory for blood culture test. -Review how compliant the client has been with ambulation. -Auscultate lung sounds.

compartment syndrome

a condition in which there is swelling within fascia that does not expand. This pressure affects blood flow to tissues and nerves

bone or muscle

a flat sound is heard over

meningococcal meningitis

a serious bacterial infection of the thin lining that surrounds the brain and spinal cord

girth

another name for circumference

Protozoa

are free-living microorganisms that commonly thrive in water

Rubs

are grating or leathery sounds caused by two dry, pleural surfaces moving over each other

Crackles

are intermittent, high-pitched, popping sounds, which are heard in distant areas of the lungs during inspiration

Gurgles

are low-pitched, continuous, bubbling adventitious sounds, which are prominent during expiration, and are heard in larger airways

Wheezes

are whistling or squeaking sounds caused by air moving through a narrow passage, which can be heard throughout the chest during expiration or inspiration

cheyne-strokes

cyclic breathing pattern characterized by periods of respiration of increased rate and depth alternating with periods of apnea

Occupational Safety and Health Administration (OSHA)

establishes regulations for safety in the physical work environment, such as air quality; ergonomics (body positioning during work maneuvers); prevention of infection transmission from used and uncapped needles that pierce the skin of a health care worker; and prevention of exposure to toxic substances

hypertension and circulatory fluid overload

forceful or bounding pulse seen in?

slight Trendelenburg

he nurse wishes to keep a client from sliding down towards the foot of the bed. Into which position will the nurse place the client? -Sims' -slight Trendelenburg -prone -supine

hypothalamus

how is body temperature regulated

pallor

if the skin appears pale, it is documented as

kussmual

increased rate (above 20 beats/min) and depth of respirations

2+ pitting edema

indicates that the indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours.

Ecchymosis

is a type of skin discoloration that results from blood underneath the skin's surface, such as in the case of a bruise.