Health Assessment Exam 2 Evolve Practice Questions

A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric tube is inserted. The healthcare provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? Instill normal saline. Assess breath sounds. Auscultate for bowel sounds. Check the tube for placement

Check the tube for placement. Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.

A nurse is obtaining a health history from the parents of a preschooler with celiac disease. What characteristic does the nurse expect when the parents describe their child's stools?

Large, pale, foul-smelling Children with celiac disease have a gluten-induced enteropathy and are unable to absorb fats from the intestinal tract, resulting in the typical characteristics of their stools. The stools are large and fatty or frothy, not mucoid. Although the stools are large and frothy, they are pale because of their high fat content. The stools are large and foul-smelling and have little color.

The nurse is administering lactulose to a client with a history of cirrhosis of the liver. The client asks the nurse why this medication is needed because the client is not constipated. How will the nurse respond?

"This medication helps you lower the high ammonia level caused by your liver disease." Lactulose is a hyperosmotic laxative and ammonia detoxicant. It decreases serum ammonia concentration by preventing reabsorption of ammonia. Lactulose has been used to lower blood ammonia content in clients with portal hypertension and hepatic encephalopathy secondary to chronic liver disease. Lactulose has no effect on the craving for alcohol or anxiety and is not prescribed to reduce abdominal distension.

The nurse is caring for a patient complaining of abdominal pain. The nurse performs an elimination assessment on the patient, and notices a swooshing sound when the vascular sounds are assessed. What is the best action by the nurse?

Notify the physician, as this is an abnormal finding.

What is the maximum heart rate of a 16 year old? Record your answer using a whole number. ____________________ beats per minute

90

A nurse identifies that a client who had a myocardial infarction is struggling with an alteration in self-concept. The nurse intervenes to promote client autonomy. Which behavior by the client demonstrates an increase in client autonomy? Active participation in providing self-care Verbalizing realistic expectations of caregivers Discussing necessary lifestyle changes with family members Listing the indicators of recovery after a myocardial infarction

Active participation in providing self-care Planning self-care demonstrates decision-making by the client; participating in care enhances feelings of self-worth and autonomy. Expectations do not reflect autonomy. Discussing necessary lifestyle changes with family members does not reflect autonomy; it may be intellectualization. Listing the indicators for recovery after a myocardial infarction does not reflect autonomy; it may be intellectualization.

The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition?

Bicarbonate 15 mEq/L An increased rate and depth of breathing is called Kussmaul respiration and occurs due to metabolic acidosis in clients with kidney disease. Serum bicarbonate level decreases in metabolic acidosis. The normal range of serum bicarbonate is 23-30 mEq/L. Therefore the bicarbonate value of 15 mEq/L is associated with Kussmaul respirations in the client. The normal serum potassium is 3.5-5 mEq/L. Therefore a potassium level of 8 mEq/L indicates hyperkalemia and is associated with changes in cardiac rate and rhythm. The normal range of hemoglobin is 12-16 g/dL in females and 14-18 g/dL in males. Therefore a Hgb of 10 g/dL indicates anemia; this is associated with fatigue, pallor, and shortness of breath. The normal range of serum phosphorous is 3-4.5 mg/dL. Therefore a phosphorous value of 7 mg/dL indicates hyperphosphatemia, which is associated with hypocalcemia and demineralization of bone.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be?

Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? Calling the primary healthcare provider Changing the maternal position Obtaining the maternal blood pressure Preparing the environment for an immediate birth

Changing the maternal position The fetus is responding to partial cord compression. Stimulation of the fetal sympathetic nervous system is evidenced by the fetal heart rate deceleration. It is an initial response to mild hypoxia that accompanies partial cord compression during contractions; changing the maternal position can alleviate the compression. This is a compensatory physiologic response by a healthy fetus; the nurse, not the practitioner, should intervene by alleviating cord compression. Taking the client's blood pressure delays nursing interventions to help the fetus. Variable decelerations are not indicative of the need for an immediate birth.

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? Call the primary healthcare provider. Check the client's pedal pulses. Take the client's blood pressure. Recognize the response is expected.

Check the client's pedal pulses These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site. A circulatory assessment should be conducted first; the primary healthcare provider may or may not need to be notified immediately concerning the results of the assessment. Taking the client's blood pressure is unnecessary; the symptoms indicate a local peripheral problem, not a systemic or cardiac problem. These symptoms are not expected.

A nurse is caring for an infant with Down syndrome. What does the nurse recall as the most common serious anomaly associated with this disorder? Renal disease Hepatic defects Congenital heart disease Endocrine gland malfunction

Congenital heart disease Many children with Down syndrome have cardiac anomalies, most often ventricular septal defects, which can be life threatening. Renal disease, hepatic defects, and endocrine gland malfunction are not characteristic findings in children with Down syndrome.

The nurse is assessing a one month old child, and notices a gap between the abdominal muscles (diastisis rectus). Which of the following is the BEST action by the nurse?

Document the normal finding. Diastsis Rectus is a normal finding in infants and newborns, documenting the normal finding would be most appropriate. The nurse would not need to notify the physician. Applying an abdominal binder is not indicated.

The nurse notices a bulge around the umbilicus of a 1 year old patient when they are asked to cough. Which of the following should the nurse do?

Document the normal findings. An umbilical hernia is common in children at that age.

The nurse is assessing the patient's pulses, and is having a difficult time palpating the brachial pulses, but notes the presence of the radial pulses. Which of the following are true? Select all that apply. Document the radial pulses. Use the doppler to locate the brachial pulses. ask the patient to show you where their pulses are Alert a physician.

Document the radial pulses.

A nurse is performing a gas exchange assessment on a male patient with thick chest hair. The nurse notes that there are crackles in the lung fields. What is the best action by the nurse?

Ensure proper positioning of the stethoscope and listen again. On a patient with thick chest hair, the nurse can hear false adventitious sounds. The best response by the nurse at this time is to check the positioning of the stethoscope and listen again. Administering furosemide as ordered may be an appropriate action once it is confirmed that the patient needs it. Alerting the physician can be appropriate once the nurse confirms that they are indeed hearing crackles. Having the patient cough will do nothing, crackles do not clear with cough and are associated with fluid.

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time? 1. Helping the client change her position 2. Informing the client of the problem with the fetus 3. Administering oxygen by mask to the client at 2 L/min 4. Readjusting placement of the fetal monitor on the client's abdomen

Helping the client change her position. Changing the maternal position is the most beneficial action, especially with late- and variable-deceleration patterns, because this position change will increase placental perfusion. Although the client should be kept informed of the fetus's condition, this may be done during or immediately after the position change; the needs of the fetus are the priority. If oxygen is used, the concentration should be greater than 2 L/min. Readjusting placement of the fetal monitor may be done after the position change; the immediate needs of the fetus are the priority.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?

Hyponatremia and decreased urine output Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema?

Left Sims To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee-chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.

Select all that apply. The nurse is assessing a patient. Which of the following indicate proper assessment techniques? Palpating before auscultating the abdomen. Listening to the breath sounds under the patient's clothing. using the palms to assess for temperature Listening in 5 spots for the heart sounds.

Palpating before auscultation can change the bowel sounds. Palpating for temperature should be done using the dorsal sides of the hands. You should have the diaphragm of the stethoscope to the skin, and listen to the heart in five places.

The nurse is assessing a patient that has come into the emergency department (ED) with shortness of breath and chest pain. Place the following actions in the order they should be done.

Perform Gas exchange assessment The priority assessment would be the gas exchange assessment, chosen by using the A-B-C's ( airway, breathing, circulation), followed by a perfusion assessment, then sensory perception.

The nurse is caring for a patient who has begun reporting bilateral lower extremity (BLE) dependent edema. What is the priority assessment for this patient?

Perfusion

What should nursing care for a child admitted with acute glomerulonephritis be directed toward?

Promoting diuresis With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.

Which electrolyte deficiency triggers the secretion of renin?

Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.

What must the nurse do to determine a client's pulse pressure? Multiply the heart rate by the stroke volume. Subtract the diastolic from the systolic reading. Determine the mean blood pressure by averaging the two. Calculate the difference between the apical and radial rate.

Subtract the diastolic from the systolic reading. Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded. Multiplying the heart rate by the stroke volume is the definition of cardiac output; it is not the pulse pressure. Determining the mean blood pressure by averaging the two is not pulse pressure. Calculating the difference between the apical and radial rate is the pulse deficit.

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?

Urinate small amount, stop flow, fill half of cup The nurse instructs the client to always collect the midstream urine to send as a test specimen. The client should be instructed to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling the cup at least half way. The client is asked to collect the first sample voided in the morning because the urine is highly concentrated in the morning. Keeping the urine sample in the refrigerator helps reduce bacterial growth due to alkaline environment. The cells in the urine sample begin to break down in alkalinity, and therefore the client is instructed to send the sample to the laboratory as soon as collected.

The nurse is caring for a patient that has complaints of chest pain and right lower extremity swelling, with redness. The physician has ruled out myocardial infarction. What diagnosis might the nurse expect the physician to order next?

V/Q scan

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause?

Warfarin Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to follow up? Whole milk with oatmeal Garden salad with olive oil Tuna fish with a small apple Soluble fiber cereal with yogurt

Whole milk with oatmeal

What things must be considered when asking about the general history of a patient in regards to elimination? Select all that apply. Nutrition Weight Abdominal or Urinary surgeries Bowel frequency

all of the above

The nurse is performing weight and height measurements as part of a well visit for a 32 year old patient. The patient is 5'3" and weighs 172 pounds. Calculate this patient's BMI, and state whether or not it is considered to be normal, overweight, or obese. (round to the nearest tenth x.x)

formula weight(lbs)*705/height (in)2, the patient's BMI is 30.55= 30.6 when rounded. This patient is considered obese by the BMI chart.