N100 Week 2 Practice

documentation of restraint checks and client status should take place at least every ___ hr

2 hrs

2+ edema

2 to 4 mm

provider's prescription renewal for restraints used continuously is every ____ hours

24

tricuspid pulse

4th left intercostal space

3+ edema

5 to 7 mm

mitral pulse

5th left intercostal space mid clavicular line

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

a nurse is teaching newly licensed nurse about heart sounds. which of the following sounds is heard when the aortic and pulmonic valves close? a. atrial gallop b. S2 c. S1 d. ventricular gallop

S2

the nurse is preparing to auscultate heart sounds after repositioning the client on the left side. which sounds should the nurse anticipate evaluating the client for? a. S3 and S4 sounds b. S1 and S2 sounds c. pulmonic valve murmurs d. tricuspid valve murmurs

S3 and S4 sounds

a nurse is assisting with teaching a class about events that require an occurence report. which of the following events should the nurse include? select all that apply. a. a client's visitor falls in the hallway b. a nurse forgets their computer password c. a client develops an unexpected reaction to a medication d. a clients dentures are lost e. an antibiotic was administered to a client 30 min after the scheduled time.

a client's visitor falls in the hallway, a client develops an unexpected reaction, a client's dentures are lost

while auscultation a client's heart sounds, the nursehears turbulence between the S1 and S2 heart sounds. the nurse should document this finding as which of the following? a. a systolic murmur b. a third heart sound c. an expected heart sound

a systolic murmur

client safety event

an unexpected event that occurred and had the potential to cause injury to the client.

the nurse is assessing a client with right lower quadrant abdominal pain. which technique should the nurse use when palpating the abdomen? a. assessing the painful area first using moderate palpation. b. assessing the painful area last using deep palpation c. assessing the painful area last using light palpation d. assessing the painful area first using deep palpation

assessing the painful are last using deep palpation

a nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. whic of the following actions should the nurse take before requesting a prescription for restraints? select all that apply. a. explain to the client that he will be restrained. b. assist the client with toileting at frequent intervals c. use an electronic position-sensitive device d. provide diversionary activities for the client e. involve the family in the client's care

assist the client with toileting at frequent intervals, provide diversionary activities for the client, involve the family in the client's care

S4 sound

atrial contraction

a client has a history of palpable submental lymph nodes. which anatomical area should the nurse assess? a. at the base of the skull b. behind the ear over the outer surface of the mastoid bone c. at the junction of the posterior and lateral walls of the pharynx at the angle of the jaw d. behind the tip of the mandible at the midline

behind the tip of the mandible at the midline

a nurse is assisting with teaching a class about hospital-acquired injuries. the nurse should include which of the following is a hospital-acquired injury? select all that apply. a. blood transfusion incompatibility b. wrong site surgery c. ineffective insulin usage d. dysphagia following a stroke e. dehydration due to diarrhea

blood transfusion incompatibility, wrong site surgery, ineffective insulin usage

a community health nurse is developing a pamphlet about breast self-examination for a local health fair. which of the following instructions should the nurse include? a. expect some breast dimpling or discharge with age. b. for those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation c. using the palm of the hand feel for lumps using a circular motion. d. breasts can be examined in the shower with soapy hands.

breasts can be examined in the shower with soapy hands

a nurse is evaulating an older client for an alteration in orientation. which of the following questions should the nurse ask the client? a. can you tell me your birthday b. can you tell me what month it is c. can you tell me what you had for lunch yesterday d. can you repeat the four words that i asked you to remember?

can you tell me what month it is

a nurse is assessing a client's vital signs. while counting the number of respirations, which of the following information should the nurse collect? a. characteristics of the respirations b. symmetric expansion of the chest walls c. shape and alignment of the rib cage d. intensity of tactile fremitus

characteristics of respirations

a nurse is performing a mobility assessment on a client. which of the following data should the nurse collect as part of this assessment. select all that apply. a. the client's ability to sit. b. the condition of the client's skin. c. the client's health literacy level d. the client's daily need for assistance with ADLs.

clients ability to sit, condition of skin, daily need for assistance with ADLs

S2 sound

closure of aortic and pulmonary valves; relaxation

S1 sound

closure of the mitral and tricuspid valves; ventricular systole

rhonchi

coarse, loud, low pitched rumbling

the nurse has elicited a blink reflex in a client. which structure of the eye is responsible for the reflex? a. lens b. macula c. cornea d. iris

cornea

near miss event

error that could have harmed the client which almost occurs, but was caught and avoided.

a nurse is preparing to conduct a fall risk screening on a client. which of the following variables will the nurse use to evaluate the client? select all that apply. a. fall history b. medical diagnosis c. use of assistive devices d. mental status e. do not resuscitate status

fall history, medical diagnosis, use of assistive devices, mental status

crackles

fine to coarse bubbly sounds

stage 3 pressure ulcer

full thickness skin loss with necrotic subcutaneous tissue

wheezing

high pitched whistling

a nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. which of the following statements by the client indicates and understanding of the teaching? a. i should soak my feet before trimming my nails. b. i should buy new shoes late in the day. c. i should wear a clean pair of nylon socks everyday d. i should use a heating pad at night when my feet feel cold.

i should by new shoes late in the day

a clients tells the nurse that he is concerned because his provider told him he has a heart murmur. the nurse should explain to the client that a murmur is: a. a high pitched sound due to a narrow valve b. is an extra sound due to blood entering an inflexible chamber c. means that there is some inflammation around the heart. d. indicates turbulent blood flow through a valve.

indicates turbulent blood flow through a valve.

a nurse is preparing to assess the status of a client's upper extremities. which of the following actions should the nurse take? select all that apply. a. inspect the condition of each fingernail b. apply a pulse oximeter to a finger c. compare the amplitude of a radial pulses bilaterally d. evaluate blood pressure in an upper extremity e. palpate the shoulder, elbow, wrist, and finger joints

inspect the condition, compare the amplitude, palpate the shoulder, elbow, wrist, and finger joints

sequence of assessing abdomen

inspection, auscultation, percussion, palpation

sequence of assessment

inspection, palpation, percussion, auscultation

a nurse is assessing a client's neck. which of the following should the nurse ask the client to perform during this assessment? select all that apply. a. instruct the client to swallow b. apply downward pressure and ask the client to shrug their shoulders c. tell the client to open their mouth and say ahh d. test the client's ability to protrude their tongue e. request the client move their head and backward and then side to side

instruct client to swallow, apply downward pressure, request the client to move their head forward

a nurse is performing a neurological assessment for a client has head trauma. which of the following assessments will give the nurse information about the function of cranial nerve III? a. instruct the client to look up and down without moving his head b. observe the client's ability to smile and frown c. have the client stand with eyes closed and touch his nose d. ask the client to shrug his shoulders against passive resistance

instruct the client to look up and down without moving his head

the nurse educator is teaching a group of nursing students to assess heart sounds. which response by a student indicates appropriate understanding of how S2 heart sounds are produced? a. it results from the closure of the mitral valve. b. it is a result from the closure of the semilunar valves. c. it results from the closure of the tricupid valve

it is a result from the closure of the semilunar valves

Pulmonary pulse

left 2nd intercostal space

Erbs point

left 3rd intercostal space

1+ edema

less than 2 mm

Rhochi

low-pitched, continuous respiratory sound that has snoring quality

the nurse is preparing to perform percussion over the lung fields of a client. which technique should the nurse use to ensure an accurate assessment is obtained? a. release the plexor immediately after the first strike. b. initiate the motion from the plexor finger c. use the pad of the flexor finger to deliver the blow d. make contact with only the pleximeter

make contact with only the pleximeter

4+ edema

more than 7mm

bronchial, bronchovesicular, vesicular

normal breath sounds

a nurse is an outpatient setting is performing a head to toe assessment on a client. which of the following should the nurse inspect when performing a general survey of the client? select all that apply a. nutritional status b. hygiene c. lung expansion d. posture e. range of motion

nutritional status, hygiene, posture

the nurse is preparing to assess for fremitus in a client. which factor should the nurse recognise may result in absent fremitus? a. obesity b. loud voice c. sinus infection d. cardiac arrhythmias

obesity

the nurse is examining a client's neck. which techniques should the nurse use to palpate the trachea? select all that apply a. palpate while the client is swallowing b. slide the thumb the index finger upward on each side c. palpate the midline of the neck to feel the cricoid cartilage d. ask the client to open and close their mouth e. stand behind the client and ask them to turn their head slightly to the right

palpate while the client is swallowing, palpate the midline of the neck to feel the cricoid cartilage

stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both

a nurse is performing a pressure injury risk assessment for a client. which of the following findings increase the client's risk of a pressure injury? a. BMI of 20 b. peripheral neuropathy c. immobility d. hypoperfusion e. prealbumin level of 16mg/dl

peripheral neuropathy, immobility, hypoperfusion

stage 1 pressure ulcer

reddened intact skin and blood filled blisters

a nurse is assessing a client's radial pulse rate. which of the following information should the nurse collect while performing this action? select all that apply. a. depth of pedal pitting edema b. regularity of the pulse c. presence of a murmur d. presence of a bruit e. strength of the pulse

regularity of the pulse, strength of the pulse

Alternatives should be considered before using _________.

restraints

aortic pulse

right 2nd intercostal space

the nurse is preparing to assess a client for heaves. which location should the nurse palpate? a. fifth intercostal space, midaxillary line b. second intercoastal space, left sternal border c. fourth intercostal space, left sternal border d. second intercostal space, right sternal border

second intercostal space, right sternal border

a nurse is assessing a client who has a new skin lesion that has a wavy border. the nurse should document the lesion using the follwoing descriptions? a. annular b. serpiginous c. circinate d. coalesced

serpiginous

the nurse is preparing to identify the angle of louis prior to a thoracic assessment. which landmark should the nurse use to identify this structure? a. clavicle b. sternum c. first rib d. vertebral column

sternum

Which is the primary landmark used to identify and locate all of the other landmarks on the anterior chest? a. sternum b. manubrium c. suprasternal notch d. angle of louis

suprasternal notch

the nurse is preparing to listen to a client's mitral valve. which landmark on the client's chest should the nurse place the bell of the stethoscope?

the apex, fifth intercostal space, left midclavicular line

a home health nurse is assessing an older adult client who reports falling a couple of times over the past week. which of the following findings should the nurse suspect is contributing to the client's falls? a. the client takes alprazolam b. the client has a nonslip bath mat in his shower c. the client uses a raised toilet seat d. the client wears fitted slippers

the client takes alprazolam

the educator has reviewed the layers of the skin with a nurse. which statement indicates further teaching is required? a. the cutaneous glands help protect against bacteria on the skin. b. the subcutaneous tissue contains half of the body's fat cells c. the dermis contains collagen and elastin fibers d. the epidermis produces melanin

the epidermis produces melanin

the educator has reviewed the respiratory system for a nurse. which statement made by the nurse indicates further teaching is required? a. the left main bronchus is shorter b. the bronchi begin at the level of the sternal angle c. the bronchi divide within each lobe of the lung d. the bronchi warm and moisten air

the left main bronchus shorter

a nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. which of the following statements should the nurse include? a. the mucous membranes secrete a thin, salty liquid that traps pathogens and particles b. the mucous membranes provide a chemical barrier against pathogens. c. the mucous membranes of the auditory tube contain cilia that move particles toward the front of the nose d. the mucous membranes in the nose contain cilia that traps particles preventing them from invading the body.

the mucous membranes in the nose that contain cilia that trap particles, preventing them from invading the body

a nurse is reviewing a list of client care tasks with another nurse. in which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? select all that apply a. the nurse's hands become visibly soiled b. the nurse removes the meal tray of a client who has infectious diarrhea c. the nurse moves the cell phone of a client who has pneumoccoccal pneumonia form the bedside table. d. the nurse empties the urinal of a client who has clostridium difficile e. the nurse is preparing to insert an intravenous catheter

the nurse's hands become visibly soiled, the nurse removes the meal tray of a client who has infectious diarrhea, the nurse empties the urinal of a client who has clostridium difficile

the nurse is assessing the client's neck. which should the nurse recognize is an abnormal finding? a. the client's carotid arteries are visibly pulsating. b. the neck is symmetrical c. the tracheal cartilage does not move when the client's swallows d. the thyroid has no palpable nodules

the tracheal cartilage does not move when the client swallows

the nurse is preparing to perform the cover and uncover test on a client. which explanation will the nurse provide the client prior to performing the exam? a. this will test the muscles that control your eye movement b. this will test the ability of your pupil size to change c. this will test the balance mechanism that keeps your eyes parallel d. this will test the ability of your eyes to focus on distant objects

this will test the balance mechanism that keeps your eyes parallel

The school nurse is assessing adolescent females for scoliosis. Which area of the spine does the nurse plan to assess? a. Thoracic b. lumbar c. cervical d. sacral

thoracic

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? a. turn the client's head to the side b. check the client's motor strength c. loosen the clothing around the client's wasit d. document the time the seizure began

turn the client's head to the side

the nurse is assessing a client's abdomen. which sound is expected when percussion is used during the assessment? a. resonance b. dullness c. tympany d. hyperresonance

tympany

a nurse is planning to perform foot care for a client. which of the following actions should the nurse plant o take? a. use warm water to wash the client's feet. b. allow the client's feet to air dry c. soak the client's feet prior to washing

use warm water to wash the clients feet

a nurse is preparing an in-service about communication for a group of staff nurses. which of the following techniques should the nurse include when diccussing therapeutic communication.

using silence

a nurse is performing a cardiac assessment on a client and auscultates an S3 sound. the nurse should recognize that this sound represents which of the following heart sounds?a a. atrial gallop b. ventricular gallop c. closur of the mitral valve d. closure of pulmonic valve

ventricular gallop

S3 sound

ventricular gallop; use bell stethoscope

a nurse is assessing a client who has an infection. which of the following findings is a manifestation of sepsis? a. vomiting b. hypoglycemia c. hypertension d. altered mental status e. elevated WBCs

vomiting, altered mental status, elevated WBCs