exam 3
A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply.
Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4 to 6 in) from the bridge of the patient's nose ask patient to look at a close object and then a far away object
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A patient is postoperative day 3 following major bowel surgery and has been reluctant to ambulate since being admitted from postanesthetic recovery 2 days ago. As a result, the patient has developed atelectasis and is now being treated for this problem. When administering the patient's bronchodilator by nebulizer, what teaching should the nurse provide?
"If possible, take slow, deep breaths while your nebulizer is running."
A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. The nurse begins teaching by stating
"Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required."
A nurse assesses an oral temperature for an adult patient and records that the patient is "afebrile." What would be the nurse's best response to this finding?
No action is necessary; this is a normal reading. afebrile= no fever
When assessing an infant's axillary temperature, it will be:
1°F (0.5°C) lower than an oral temperature.
All of the following patients have a body temperature of 38°C (100.4°F). About which patient would a nurse be most concerned?
2 month old infant
Which action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered.
The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?
40% circumference of limb
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/minute. What number would the nurse document for this assessment?
5,850 mL. stroke volume X heart rate
Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V.
Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure The last sound heard before a period of continuous silence, known as the second diastolic pressure
A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a vital sign within normal limits? Select all that apply.
A 4-month-old infant whose temperature is 38.1°C (100.5°F) An adolescent whose pulse rate is 70 beats/min An adult whose respiratory rate is 20 breaths/min A 72-year-old whose pulse rate is 42 beats/min
You are preparing to measure a patient's rectal temperature. Which of the following supplies and equipment should you have available before beginning the procedure? Select all that apply.
An electronic thermometer with a rectal probe Disposable probe cover Water-soluble lubricating gel
A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply.
An increase in the pulse rate an increase in respiratory rate
A nurse attempts to count the respiratory rate for a patient via inspection and finds that the patient is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this patient?
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
a ultrasonic doppler is used for
Auscultating a pulse that is difficult to palpate
A 72-year-old patient who was admitted to the hospital for a total hip arthroplasty has developed increasing dyspnea and leukocytosis over the past 48 hours and has been diagnosed with hospital-acquired pneumonia (HAP). The choice of antibiotic therapy for this patient will be primarily based on which of the nurse's assessments?
Collection of a sputum sample for submission to the hospital laboratory
A nurse caring for adults in a provider's office researches aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply.
Decrease in size and function of the thymus results in more infections. There is much interest in the role of vitamin supplementation.
You are preparing to assess a patient's oral temperature. You should plan to place the thermometer probe in which of the following areas of the patient's mouth?
Deep in the posterior sublingual pocket
A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding?
Document and report the finding of abnormal Rhonchi breath sounds
Assessment order
Inspection Palpation Percussion Auscultation
During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?
Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.
A nurse is using the circular technique to palpate the breast of a woman during an assessment. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall. How would the nurse proceed with the palpation?
Start at the tail of Spence and move in increasing smaller circles.
The nurse places a patient in the dorsal recumbent position during a physical assessment. Which nursing actions could the nurse perform with the patient in this position? Select all that apply.
Taking peripheral pulses Performing a breast examination Auscultating the heart
four coma scale
eye response, motor response, brainstem reflexes, and respiration pattern (best score is 4)
The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?
The first appearance of faint but distinctive tapping sounds
Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply.
The nurse takes a patient's pulse. The nurse touches a patient's skin to test for turgor. The nurse checks a patient's lymph nodes for swelling.
A nurse is assessing a newborn at the healthcare facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?
immature ability to regulate temperature in general
Upon auscultation of a patient's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the patient is exhibiting signs of which of the following?
a dysrhythmia
The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply.
a newborn who has hypothermia An older adult who is post MI (heart attack) A teenager who has leukemia A patient receiving erythropoietin to replace red blood cells
A nurse is caring for older adults in a senior adult day services (ADS) center. Which findings related to the normal aging process would the nurse be likely to observe? Select all that apply.
a patient with skin pigmentation from sun exposure over the years A patient healing from a hip fracture that occurred due to porous and brittle bones Bruising on a patient's forearms due to fragile blood vessels in the dermis
petechiae
a small red or purple spot caused by bleeding into the skin.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
ability of arteries to stretch
ADL = BATHED
activities of daily life bathing, ambulation, toilet, transfers, eating, dressing
locations of where you listen to heart sounds
aortic, pulmonic, tricuspid, mitral APe To Man
A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first?
assess infant's oxygen saturation
where do you listen to aortic and pulmonic valves
base
cyanosis
bluish discoloration of the skin
While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patient's respiratory rate is 8 breaths/min. How will the nurse interpret this finding?
bradypnea is a response to IICP
Ecchymosis
bruise
The systolic is the measurement of
pressure at peak force
The diastolic is the measurement of
pressure in your heart at REST
fluid in the lungs sound like
crackles
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what?
decrease apical pulse
pulse pressure
difference between systolic and diastolic pressure
pulse deficit
difference between the apical and radial pulse rates
A nurse is caring for a client with orthostatic hypotension. Which of the following are symptoms of orthostatic hypotension? Select all that apply.
dizziness syncope weakness
A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply.
do you dress yourself? do you prepare your own meals? do you manage your own finances?
A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?
dyspnea
A patient is experiencing dyspnea. What is the nurse's priority action?
elevate the head of the bed dyspnea= labored breathing
vessicle
fluid filled sac (blister)
A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
follow up measurements of blood pressure always double check first
health history vs physical assessment
health history is subjective physical assessment is objective
vasoconstriction
higher bp
A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized?
imapired gas exchange
Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
increased pulse rate
The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the:
infant SUPINE
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?
inflate 30 mm above the auscultatory gap
While assessing a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen?
inner bottom
Abdomen assessment order
inspection, auscultation, percussion, palpation
breast examination
lesions, scars, posture, gait, attitude, temperature, pain/tenderness
A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as:
less than normal vision
vasodialation
lower bp
A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for which treatment?
starting oxygen
When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What does this finding indicate?
narrowed airways makes a wheezing sound
The nurse is caring for an infant in the emergency room who has symptoms of irritability and a high fever. When assessing for increased intracranial pressure using the anterior fontanel, identify the area where the nurse would palpate.
open space in front
What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?
oral
The nurse places a patient experiencing labored breathing in an upright position. The nurse notes that the patient is able to breathe more easily in this upright position and documents this condition on the chart as which of the following?
orthopnea
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis?
pain in the calf
toddler should be where for temporic temperature
parents lap
An RN working in a hospital setting is responsible for patient assessment. For which patient would the nurse perform a focused assessment?
patient with diabetes who develops secondary hypertension
Which patient would the nurse consider at risk for low blood pressure?
patient with low blood volume
Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apicalradial pulse indicates that the two values differ significantly, a finding that suggests which of the following health problems?
peripheral vascular disease
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?
provide privacy
what valves close during end of systole/ beginning of diastole s2?
pulmonic and aortic
Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats/min. How will the nurse document this difference?
pulse deficit
erythema
red skin
The nurse is taking a rectal temperature on a patient who reports feeling light-headed during the procedure. What would be the nurse's priority action in this situation?
remove thermometer and assess blood pressure and heart rate
primary organ of heat loss
skin
symptoms vs signs
symptoms are subjective signs are objective
After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 130/82. Based on the collected data, which step would the nurse take next?
take pulse again to assess for tachycardia
A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:
the highest pressure present on arterial walls while the ventricles contract.
A toddler has a temperature above 101°F (38.3°C). The healthcare provider orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of:
thrombocytopenia
what valves close during systole s1?
tricuspid and mitral
Upon assessment of a patient, the nurse determines that a patient is at risk of losing body heat through the process of convection. What would be the nurse's best response?
turn off overhead fan
breast examination
visual inspection and manual examination of the breast for changes in contour, symmetry, dimpling of skin, retraction of the nipple, and the presence of lumps
The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?
would you consider using a digital thermometer?
jaundice
yellowing of the skin
if you use wrong size cuff
you can get an incorrect reading
