NCLEX 3500

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?

"At first, the stoma may bleed slightly when touched."

To evaluate a client's cerebellar function, the nurse should ask:

"Do you have any problems with balance?"

To help assess a client's cerebral function, the nurse should ask:

"Have you noticed a change in your memory?"

The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?

"I've cut my smoking down from two packs to one pack a day."

A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:

"What does the pain feel like?"

The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?

-when did the rash start -are you allergic to any meds, foods, or pollen -what have you been using to treat the rash -have you recently traveled outside the country

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

38.9° C

Which of the following factors are major components of a client's general background drug history?

Allergies and socioeconomic status

The nurse is assessing a client's pulse. Which pulse feature should the nurse document?

Amplitude

When should the nurse check a client for rebound tenderness?

At the end of the examination

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?

Auscultation, percussion, and palpation

Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client?

Because the child may cry as the assessment proceeds, making auscultation difficult

When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

Constriction and convergence

The nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

Cultural influences

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

Effective breathing at a rate of 16 breaths/minute through the established airway

Which plane divides the body longitudinally into anterior and posterior regions?

Frontal plane

The nurse conducts a test for the Romberg's sign. What is the correct procedure for this test?

Have the client stand with feet together and arms at the sides and try to balance, first with eyes open and then with eyes closed.

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

Infection

The nurse is assessing a client's abdomen. Which examination technique should the nurse use first?

Inspection

When performing an abdominal assessment, the nurse should follow which examination sequence?

Inspection, auscultation, percussion, and palpation

A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?

Intradermal drugs diffuse more slowly.

Why shouldn't the nurse palpate both carotid arteries at one time?

It may cause severe bradycardia.

When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

Lag

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

Middle-old

Why should an infant be quiet and seated upright when the nurse assesses his fontanels?

Lying down and crying can cause the fontanels to bulge.

During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data?

Objective

The nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

The client can read from 20′ (6 m) what a person with normal vision can read at 40′.

To evaluate a client's posterior tibial pulse, where should the nurse palpate?

On the inner aspect of the ankle, below the medial malleolus

To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

Organs

The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Potential for drug dependence

The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release

The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

Rinne test

The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

Shifting dullness over the abdomen

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

Temporal

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation.

The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

The diaphragm detects high-pitched sounds best.

Which of the following is the most common source of airway obstruction in an unconscious victim?

The tongue

Which descriptions are true about crackles?

They may be fine, medium, or coarse.

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

To compensate for the effects of activity on the heart rate

When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?

To identify genetic and familial health problems

The nurse correctly identifies which items as belonging to the dorsal cavity?

Vertebral canal

When routinely evaluating a geriatric client for any atypical signs or symptoms, the nurse should remember that:

aging can reduce the body's ability to regulate body temperature.

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

allowing extra time for the assessment.

When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:

closing of the aortic and pulmonic valves

When assessing a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:

delayed gastric emptying.

The nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

failing eyesight, especially close vision.

Tachycardia can result from:

fear, pain, or anger.

The nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client's ear by pulling the:

helix up and back.

A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:

higher systolic blood pressure reading.

Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

keep the client warm.

When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

nothing abnormal.

Hyperactive bowel sounds can result from all of the following except:

paralytic ileus.

The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

progressively deeper breaths followed by shallower breaths with apneic periods.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:

tachycardia.

The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

thirst or confusion.

A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

touching the uvula.

The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:

ulnar surface of the hand.

When palpating the bladder of an adult client, the nurse should identify which finding as normal?

A nonpalpable bladder

The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands?

Below the cheekbones

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

Carotid

Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

Carotid

Which of the following sentences correctly describes the anatomic position?

Palms are turned forward.

During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?

Palpation

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the tongue.

The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:

inelastic skin turgor is a normal part of aging.

The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called:

the pulse deficit.

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

Level of consciousness (LOC)

A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

Vesicles

Which statement regarding heart sounds is correct?

S1 is loudest at the apex, and S2 is loudest at the base.

When examining a client with abdominal pain, the nurse should assess:

the symptomatic quadrant last.

The nurse prepares to perform light palpation. How is light palpation performed?

By indenting the skin ½" to ¾" (1.3 to 1.9 cm)

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

Circumscribed, elevated, and filled with serous fluid

The nurse is assessing a postoperative client. Which of the following should the nurse document as subjective data?

Client's description of pain

The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

Compare the capillary refill of each extremity, making sure it's the same bilaterally

All of the following components may be part of a client's medical record. Which one is the major source of subjective data about the client's health status?

Health history

At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

Notify the physician immediately of these findings

When percussing a client's chest, the nurse should identify which sound as a normal finding?

Resonance

The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3-, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

The nurse can auscultate for heart sounds more easily if the client is:

leaning forward.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is most likely to detect:

left calf circumference 1" (2.5 cm) larger than the right.

When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

the history of the present problem, allergies, medications, and recent major operations.

The ear canal of an infant or young child:

slants upward.

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should

withhold food and fluids.

The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

The nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

use the bell of the stethoscope.