NSL212 Final Exam
IM Needle Length
1-1.5 in
How many thoracic vertebrae are there?
12
normal respirations in an adult
12-20 bpm
normal BP in an adult
120/80 mm Hg
What is a normal angle of attachment for nails?
160º
IM Needle Gauge
18-25
What is a normal AP lateral ratio for infants?
1:1
what is a normal AP ratio
1:2
How long should capillary refill be?
2-3 seconds
SQ Needle Gauge
23-30
Where can the pulmonic valve be auscultated?
2nd ICS left sternal border
Where can the aortic valve be auscultated?
2nd ICS right sternal border
Bowel sounds should be auscultated in how many places in the abdomen? A. 1 B. 2 3. 4 D. 9
3. 4 Bowel sounds should be auscultated in all four quadrants of the abdomen.
SQ Needle Length
3/8-5/8 inch
Where can the tricuspid valve be auscultated?
4th ICS left sternal border
How many lumbar vertebrae are there?
5
What is a normal grade of muscle strength?
5
Where can the mitral valve be auscultated?
5th ICS mid clavicular line
Normal pulse rate in an adult
60-100 bpm
How many cervical vertebrae are there?
7
What is a normal costal angle?
90º
normal pulse ox
95%-100%
what is the mean body temperature?
97.9º F
A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." Which is the best response by the nurse? A. "Your vital signs are stable, but there are other things to monitor." B. "We still need to keep monitoring your blood pressure for a while." C. "The vital signs confirm that your infection is resolved; how do you feel?" D. "I'll let your healthcare provider know so that you can be discharged."
A. "Your vital signs are stable, but there are other things to monitor."
How many sections of the right lung? A. 3 B. 2
A. 3
How deep is deep palpation of the abdomen?
A. 5-6in B. 2-3cm C. 1cm D. 2-3in
Severe head injury on the Glasgow Coma scale is a score of: A. 8 or less B: 9-12 C. 13-15
A. 8 or less
Which of the following statements would be appropriate for a Review of Systems for the abdomen? Select all that apply. A. A history of heartburn after eating high fat meals. B. Reports of five pound weight loss in the last month. C. History of constipation, relieved with milk of magnesia D. Liver percussed in RUQ within costal margin E. No costovertebral angle (CVA) tenderness
A. A history of heartburn after eating high fat meals. B. Reports of five pound weight loss in the last month. C. History of constipation, relieved with milk of magnesia
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? A. A salmonella infection that occurs after eating contaminated food from the cafeteria. B. An infection that occurs during a therapeutic procedure. C. A yeast infection that occurs while receiving D. A urinary tract infection that occurs after a sterile catheter insertion.
A. A salmonella infection that occurs after eating contaminated food from the cafeteria.
Which set of vital signs are all within normal limits for patients at rest? A. Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg B. Older adult: T 98.6°F 37°C) (oral); HR 110; RR 28; BP 170/100 mm Hg C. Adult: T 99.6°F (37.6°C) (oral); HR 48; RR 22; BP 130/84 mm Hg D. Infant: Temperature (T) 98.8°F (37.1°C) (rectal); heart rate (HR) 160; respiratory rate (RR) 16; blood pressure (BP) 120/54 mm Hg
A. Adolescent: T 98.2°F (37°C) (oral); HR 80; RR 18; BP 108/68 mm Hg
A patient with tuberculosis is admitted to the hospital. Which precautions must the nurse institute when caring for this patient? A. Airborne transmission B. Droplet transmission C. Primary infection D. Direct contact
A. Airborne transmission
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39ºC (102ºF). Which of the following other vital signs should the nurse expect? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate.
A. An elevated pulse rate A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.
The nurse is preparing to administer a subcutaneous dose of insulin to a patient with diabetes. Which two sites might the nurse use that would provide the fastest absorption of the injection? Select all that apply. A. arm B. thigh C. Abdomen D. Ventral forearm
A. Arm C. Abdomen
The nurse is performing an abdominal assessment on a client with irritable bowel syndrome. The nurse has just finished inspection of the abdomen. Which action should the nurse take next? A. Auscultate for bowel sounds B. Feel for masses C. Percuss for presence of air D. Palpate for distention
A. Auscultate for bowel sounds
A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? Select all that apply. A. BMI of 35 B. The client has had nausea for 2 days. C. The client is reporting a stuffy nose D. The client has been fasting for blood tests E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.
A. BMI of 35 C. The client is reporting a stuffy nose E. The client is taking digoxin for an irregular heart rate. F. The client had a mastectomy 2 years ago.
A client has noticed a decrease in taste sensation. Which cranial nerve (CN) is most likely involved? A. CN VII and CN IX B. CN V and CN VII C. CN V and CN VIII D. CN VI and CN X
A. CN VII and CN IX
The nurse just finished inserting an indwelling urinary catheter into a client and is sitting down to document the procedure. Which information should the nurse include in the medical record? Select all that apply. A. Catheter size B. Provision of privacy C. Date and time of insertion D. Projected date of removal E. Amount of saline in balloon F. Color, clarity, and amount of urine return
A. Catheter size C. Date and time of insertion E. Amount of saline in balloon F. Color, clarity, and amount of urine return
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? A. Crackles B. Stridor C. Wheezes D. Friction rub
A. Crackles
When inspecting the patient, the nurse observes: (select all that apply) A. Distention B. Tenderness C. Striae D. Dilated veins
A. Distention C. Striae D. Dilated veins B, Tenderness, is not observed. It is palpated.
Fluid or solid tissue in the lung creates: A. Dullness to percussion B. A decrease in tactile fremitus C. A suggestion of COPD or asthma D. Hyper resonance to percussion
A. Dullness to percussion
Glossopharyngeal and vagus nerve damage may cause the client to experience which of the following? A. Dysphagia B. Dysuria C. Hyporeflexia D. Decorticate
A. Dysphagia
Which interventions should the nurse instruct the client to perform to decrease the incidence of urinary incontinence? Select all that apply. A. Eliminate caffeine from the diet B. Limit fluid intake C. Stop smoking D. Lose weight E. Increase the use of artificial sweeteners
A. Eliminate caffeine from the diet C. Stop smoking D. Lose weight
The patient reports having difficultly brushing her hair and pulling it back up in a hair tie. Which shoulder ROM is being limited? A. External Rotation B. Internal Rotation
A. External rotation
Which intervention by the nurse helps to establish a trusting nurse-patient relationship? A. Greeting the patient by name whenever entering the patient's room B. Avoiding topics that may provoke emotional responses from the patient C. Listening to the patient while performing care activities D. Performing care interventions quietly without explanation
A. Greeting the patient by name whenever entering the patient's room
Which is not a common indication of a UTI? A. Increased thirst B. Worsening confusion C. Left flank pain D. Temperature of 38ºC/100.4ºF
A. Increased thirst
Which of the following routes of medication administration has no barriers to absorption? A. Intravenous B. Intramuscular C. Subcutaneous D. Oral
A. Intravenous
Accentuated thoracic curve A. Kyphosis B. Scoliosis C. Lordosis
A. Kyphosis
You evaluate that the enemas have had the desired effect when you find which of the following? A. Large amount of slightly discolored solution with no solid fecal matter B. Large amount of clear solution with several pea-sized flecks of stool C. Large formed stool in a large amount of clear solution
A. Large amount of slightly discolored solution with no solid fecal matter
When performing a self breast exam, the patient should: (select all that apply) A. Lay supine with arm overhead B. Perform in the shower C. Perform 7 days before menstruation D. Perform 7 days after menstruation
A. Lay supine with arm overhead B. Perform in the shower D. Perform 7 days after menstruation
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A. Lordosis B. Ankylosis C. Kyphosis D. Scoliosis
A. Lordosis
The nurse finds a small pulsation at the patient's fifth intercostal space midclavicular line. This should be documented as a: A. Normal finding B. Thrill C. Heave D. Murmur
A. Normal finding Sometimes, the PMI can be seen.
Which of the following actions would be most appropriate to assess the carotid arteries? A. Palpate each artery individually to compare B. Use the diaphragm of the stethoscope C. Palpate the arteries before auscultating them. D. Ask the client to breathe in and out deeply.
A. Palpate each artery individually to compare
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A. Place the client in the dorsal recumbent position on a bedpan. B. Administer the enema while the client sits on the toiler. C. Administer an antidiarrheal medication 3 hr prior to the enema. D. Instill 200mL of fluid over an hour at 15 min intervals.
A. Place the client in the dorsal recumbent position on a bedpan. A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled.
A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Position the client supine B. Deflate the catheter balloon using a sterile syringe C. Measure and document the urine in the drainage bag D. Remove the tape or device securing the catheter to the client's thigh
A. Position the client supine C. Measure and document the urine in the drainage bag
To promote the client's comfort during the administration of the enema solution, which of the following actions should you take? (select all that apply). A. Preheat the normal saline solution to lukewarm prior to administration. B. Lubricate the tip of the rectal tube before inserting it into the clients anus C. Point the tip of the enema tube toward the client's umbilicus while inserting it. D. Insert the tip of the tube approx. 5-7in. into the rectum. E. Have the client bear down as you insert the tube and start the flow of solution.
A. Preheat the normal saline solution to lukewarm prior to administration. B. Lubricate the tip of the rectal tube before inserting it into the clients anus C. Point the tip of the enema tube toward the client's umbilicus while inserting it.
What is the correct order in auscultating bowel quadrants? A. RLQ, RUQ, LUQ, LLQ B. RLQ, LUQ, LLQ, RUQ C. LUQ, RUQ, LLQ, RLQ
A. RLQ, RUQ, LUQ, LLQ Auscultate starting in the RLQ and proceed in a clockwise manner.
Which of the following would the nurse consider to be risk factors when considering a patient's cardiovascular status? (select all that apply) A. Random blood pressure of 132/68 B. High stress C. Smoking D. Diet high in concentrated sweets
A. Random blood pressure of 132/68 B. High stress C. Smoking
The ____ lobe of the lungs is best auscultated from the anteriolateral chest. A. Right midde B. Right lower C. Left lower D. Left upper
A. Right midde
Before administering a medication, the nurse must verify the six rights of medication administration, which are: A. Right patient, right drug, right dose, right route, right time, and right documentation B. Right drug, right dose, right route, right time, right physician, and right documentation C. Right patient, right room, right drug, right route, right dose, and right time D. Right patient, right drug, right route, right time, right documentation, and right equipment
A. Right patient, right drug, right dose, right route, right time, and right documentation
Lower in pitch, lasts longer A. S1 B. S2
A. S1
Which heart sound would the student associate with systole? A. S1 B. S2 C. S3 D. S4
A. S1
In light of the client's gram stain results (which indicate neisseria gonorrhoeae), it is appropriate for you not only to notify the provider for a prescription but also to notify: A. The local office of the state's health department. B. The client's spouse. C. Any health care team members who have had contact with the client.
A. The local office of the state's health department. Health care professionals in every state in the US must report every diagnosed case of n. gonorrhoeae so each client receives adequate follow-up care and anyone who has had sexual relations with the client is identified and treated.
The student nurse asks the healthcare provider if an indwelling urinary catheter will be prescribed for a hospitalized patient who is incontinent. The healthcare provider explains that catheters should be utilized only when absolutely necessary because: A. They are the lading cause of healthcare associated infections B. They are too expensive for routine use C. They contain latex, increasing the risk for allergies D. They are painful on insertion for most patients
A. They are the lading cause of healthcare associated infections
Which are reasons for a nurse to perform a nursing assessment of a client? Select all that apply. A. To obtain baseline information B. To develop a plan for nursing care C. To evaluate effectiveness of interventions D. To receive reimbursement for services provided E. To determine the presence of disease & its pathology
A. To obtain baseline information B. To develop a plan for nursing care C. To evaluate effectiveness of interventions
Which are reasons for a nurse to perform a nursing assessment of a client? Select all that apply. A. To obtain baseline information B. To develop a plan for nursing care C. To evaluate effectiveness of interventions D. To receive reimbursement for services provided E. To determine the presence of disease and its pathology
A. To obtain baseline information B. To develop a plan for nursing care C. To evaluate effectiveness of interventions
A high-pitched heart sound that has a louder S1 sound and is heard best at the apex of the heart would represent the start of systole. A. True B. False
A. True
During pregnancy, the lumbar region of the spine can curve inward, causing the belly & buttocks to protrude. This is known as lordosis. A. True B. False
A. True
nurse is caring for a client who has been admitted to the neurological unit for evaluation of dizziness and reports of the "room spinning when lying down." The nurse should document this finding as which of the following? A. Vertigo B. Diplopia C. Orthostatic hypotension D. Bradycardio
A. Vertigo
High-pitched breath sounds produced by airway narrowing are known as: A. Wheezing B. Crackles C. Rales D. Rhonchi
A. Wheezing
In nursing assessment, GU stands for: A. genitourinary B. gastrourinary
A. genitourinary
When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to: A. hyperinflation of the lungs B. Long-term chronic hypoxia C. Collapse of distal alveoli D. Use of accessory muscles
A. hyperinflation of the lungs
The most important lifestyle changes a client can make to improve cardiovascular health? A. quit smoking B. Living a more sedentary lifestyle C.. Eating a high fat diet D. Getting more rest than exercise
A. quit smoking
Hyperactive bowel sounds are: A. very high-pitched and more frequent than normal. They may occur with small bowel obstruction and inflammatory disorders. They indicate hyperperistalsis, which can result in diarrhea. B. high-pitched, with approximately 5-15 gurgles every minute. C. If you hear no bowel sounds after listening in a quadrant for 3-5 minutes, you should listen in several areas before describing them as absent. Absent bowel sounds indicate a lack of intestinal activity, which may occur after abdominal surgery and may indicate a paralytic ileus. D. low-pitched, infrequent, and quiet. A decrease in bowel sounds indicate decreased peristalsis, which can result in constipation.
A. very high-pitched and more frequent than normal. They may occur with small bowel obstruction and inflammatory disorders. They indicate hyperperistalsis, which can result in diarrhea.
SQ Sites
Abdomen, upper arm
CN VI
Abducens
What does ADPIE stand for
Assessment Diagnoses Planning Implementation Evaluation
The client asks about obtaining an enema. Which of the following responses should the nurse make? A. "Just take your prescription to your local pharmacy. The pharmacist will dispense the enema solution." B. "A hypertonic enema is an over-the-counter item. You'll find it in the same aisle as medication for stomach problems." C. "Just ask for an enema kit at the pharmacy counter. It will contain the bag and the solution."
B. "A hypertonic enema is an over-the-counter item. You'll find it in the same aisle as medication for stomach problems." As an over-the-counter product, hypertonic enemas do not require a prescription. It is helpful to suggest the most common location to look for these products in typical pharmacies since the client is reluctant to ask a clerk for assistance.
When testing near vision, the nurse should position printed text how many inches away from the patient? A. 20 (50.8 cm) B. 14 (35.5cm) C. 16 (40.4 cm) D. 18 (45.7 cm)
B. 14 (35.5cm)
How deep is light palpation of the abdomen? A. 5cm B. 1cm C. 2cm D. 3 in
B. 1cm
How many sections of the left lung? A. 3 B. 2
B. 2
How far should the tip of an enema be inserted? A. 1-2in B. 3-4in C. 5-6in D. 8-10in
B. 3-4in
How long should a cleansing enema be retained for? A. 15-20min B. 5-15min C. 30-45min D. 5-10min
B. 5-15min
Where is the best landmark to palpate the apical pulse? A. 3rd ICS left midclavicular line B. 5th ICS left midclavicular line C. 3rd ICS right midclavicular line D. 5th ICS right midclavicular line
B. 5th ICS left midclavicular line
The nurse questions an order for an indwelling catheter for which of the following patients? A. 78 y/o female with dementia and a stage III ulcer on the sacrum B. 72 y/o female having outpatient surgery for an eye cataract C. 68 y/o male who had a total knee replacement and is now having urinary retention D. 80 y/o male who has had prostate surgery
B. 72 y/o female having outpatient surgery for an eye cataract
The drug name "Tylenol" is considered: A. A generic name B. A brand name C. A chemical name
B. A brand name
The nurse is reviewing the structures of the heart. Which part is the pericardium? A. Two thin-walled muscles that receive blood into the heart B. A sac of connective tissue that encases the heart C. Two thick-walled muscles that pump blood out of the heart D. The nerve tissue that acts as the pacemaker
B. A sac of connective tissue that encases the heart
The patient remembers their name and where they are, but does not know the date or time of day. The nurse would document this as: A. AAO x 1 B. AAO x 2 C. AAO x 3 D. AAO x 4
B. AAO x 2
Which term refers to the movement of a drug from the site of administration to the bloodstream? A. Distribution B. Absorption C. Excretion D. Metabolism
B. Absorption
You have cleansed the urethral meatus three times and are about to insert the catheter. Your client repositions herself, causing the labia to close briefly over the urethra. Which of the following should you do next? A. Restrain the client and start the procedure over, using a new sterile catheterization kit. B. Ask an assistive personnel to help and then apply sterile gloves; re-cleanse the meatus with sterile antiseptic. C. Quickly insert the catheter before further contamination can occur.
B. Ask an assistive personnel to help and then apply sterile gloves; re-cleanse the meatus with sterile antiseptic. The meatus has become contaminated. The nursing assistant can help orient the client. The appropriate next step is to clean the meatus again.
Which of the following assessment findings are expected when auscultating the abdomen? A. Silent abdomen B. Borborygmi C. Vascular sounds D. Bowel sounds heard every 1-3 minutes
B. Borborygmi
The correct steps for obtaining a urine sample from a closed system are which of the following? A. Disconnect the collection bag from the drainage tubing, cleanse the end of the tube with an aseptic solution, and allow urine to flow from the tube into a specimen bottle. B. Collect 5-10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode. C. Allow all the urine to collect in the bag and then empty the bag and collect urine from the collection port.
B. Collect 5-10 mL of urine from the collection bag into a sterile specimen container before emptying urine from the collection bag into the commode. When the collection bag is new, it is still sterile and uncontaminated. For the first sample, the nurse can collect the sample from the collection bag. Any other samples will need to be obtained from the collection tube.
Which procedure technique has the most effect on the accuracy of an irregular apical pulse count? A. Using the ring finger to palpate the intercostal spaces B. Counting the rate for 1 full minute C. Determining why assessment of apical pulse is indicated D. Exposing only the left side of the chest
B. Counting the rate for 1 full minute
The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply. A. Sodium B. Creatinine C. RBC D. BUN E. GFR
B. Creatinine D. BUN
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? A. Document accurate data B. Develop a plan of care C. Validate previous data D. Evaluate outcomes of care
B. Develop a plan of care
What position should the female patient assume before the nurse inserts an indwelling urinary catheter? A. Semi-Fowler's B. Dorsal recumbent C. Modified trendelenburg D. Prone
B. Dorsal recumbent
The glasgow coma scale is divided into three areas: they include (select all that apply): A. Pupillary response to light B. Eye opening C. Motor response to stimuli D. Verbal response
B. Eye opening C. Motor response to stimuli D. Verbal response
A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. Which of the following body movements should indicate to the nurse that the client has full ROM of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180º angle C. Abducting the arm to a 90º angle from the side of the body D. Circumducting the shoulder in a 180º half circle
B. Flexing the shoulder by raising the arm from a side position to a 180º angle
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A. Inversion and eversion B. Flexion and extension C. Circumduction D. Supination and pronation
B. Flexion and extension
Which should be removed first? A. Gloves B. Gown C. The field shield D. The N95 respirator
B. Gown
When assessing your patient's muscle strength, you not that they have full ROM against gravity and some resistance (slight weakness). How would you grade this? A. Grade 5 B. Grade 4 C. Grade 3 D. Grade 2 E. Grade 1 F. Grade 0
B. Grade 4
The proper sequence for the abdomen assessment is: A. Inspection, Percussion, Palpation, Auscultation B. Inspection, Auscultation, Percussion, Palpation C. Inspection, Palpation, Percussion, Auscultation D. Inspection, Auscultation, Palpation, Percussion
B. Inspection, Auscultation, Percussion, Palpation
Which is an appropriate nursing intervention for the client at risk for aspiration? A. Give the client thin liquids B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw D. Encourage the client to lie down after meals
B. Instruct the client to tuck her chin when swallowing.
When assessing your patient's ROM, the patient is able to turn their forearm inward and outward. How would you document this ROM? A. Pronation and supination B. Inversion and eversion C. Pronation and Inversion D. Supination and inversion
B. Inversion and eversion
Which of the following describes a medication's generic name? A. It is the chemical name for a medication B. It is the same as its nonproprietary name. C. It is the name under which a medication is marketed D. It is the formal name of a particular medication
B. It is the same as its nonproprietary name. ex. acetaminophen is the generic name for tylenol
Which of the following is a finding of scoliosis? A. Lateral deviation of the head in relation to the spine B. Lateral curvature of the spine C. Exaggerated curvature of he thoracic spine D. Exaggerated curvature of the lumbar spine
B. Lateral curvature of the spine Not A, because only the head is deviated. Not the spine, which would indicate scoliosis.
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A. Grasp the penis at its base. B. Lift the penis perpendicular to the body. C. Hold the penis parallel to the client's body. D. Lift the penis to a 45º angle to the client's body.
B. Lift the penis perpendicular to the body. Lifting the penis to a position perpendicular to the body, or at a 90º angle, while applying light traction straightens the urethral canal to facilitate catheter insertion.
Which body organ is primarily responsible for the metabolism of medications? A. Skin B. Liver C. Large intestine D. Kidney
B. Liver
The following medication order is considered a single order: A. Acetaminophen 650mg PO every 6 hours PRN B. Lorazepam 2mg PO now C. Diltiazem 30mg PO daily D. Atorvastatin 40mg PO Daily at bedtime
B. Lorazepam 2mg PO now
Which of the following findings from a musculoskeletal assessment should be reported to the provider? A. Hollows present on either side of the olecranon process B. Misalignment of the bones of the elbow C. Rating of 5 on the muscle strength scale when evaluating the shoulder D. Absence of ulnar deviation of the fingers
B. Misalignment of the bones of the elbow
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states the the radial pulses are "2+.bilaterally" The nurse recognizes that this reading indicates what type of pulse? A. Bounding B. Normal C. Absent D. Weak
B. Normal
The patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which type of infection does this best describe? A. Unavoidable occurance B. Nosocomial infection C. Multidrug-resistant organisms D. Healthcare-associated infection
B. Nosocomial infection
The nurse is teaching a group of teenagers the best time to perform a self testicular exam. The nurse teaches them to perform this: A. Every day just as you wake in the morning B. Once a month after a shower C. Two times per year
B. Once a month after a shower
A nurse is assessing a client who reports pins and needles sensations to their right hand. Which of the following terms should the nurse use to describe the sensations? A. Proprioception B. Paresthesia C. Dysesthesia D. Sprain
B. Paresthesia Not C- Dysesthesia is a painful burning, but not pins and needles.
In a blood pressure of 123/78, 78 reflects the A. Pressure present in arteries during contraction of heart ventricles B. Pressure present in arteries while ventricles are at rest C. Difference between systolic and diastolic pressure D. Pulse pressure
B. Pressure present in arteries while ventricles are at rest
A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A. Wear a respirator B. Protect their eyes C. Put on clean gloves D. Wear shoe covers
B. Protect their eyes
Prior to entering the surgical-scrub area, which of the following PPE items should a nurse don? A. Gown B. Protective eyewear C. Hair cover D. Mask E. Shoe covers
B. Protective eyewear C. Hair cover D. Mask E. Shoe covers
When auscultating the abdomen, which quadrant do you start in? A. RUQ B. RLQ C. LUQ D. LLQ
B. RLQ Many nurses start in the right lower quadrant, since bowel tones are usually active around the ileocecal valve, which is in that quadrant.
The liver is located in the: A. LUQ B. RUQ C. LLQ D. RLQ
B. RUQ
A client who is postoperative is experiencing abdominal distention and is having difficultly expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? A. Cleansing B. Return-flow C. Medicated D. Oil-retention
B. Return-flow Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.
Higher in pitch, shorter duration A. S1 B. S2
B. S2
Lateral 'S' deviation of the spine A. Kyphosis B. Scoliosis C. Lordosis
B. Scoliosis
After inserting a catheter, you do not observe any return of urine. Abdominal palpation suggests that your client's bladder remains distended. Which of the following actions should you take next? A. Remove the catheter and repeat the procedure with a sterile, larger-diameter catheter. B. Slowly advance the catheter tip while gently rotating the tubing. c. Apply gently pressure to the distended abdomen and observe for urine return.
B. Slowly advance the catheter tip while gently rotating the tubing. If no urine appears and you have checked that the catheter is not inside the vagina, continue advancing the catheter slowly and gently until urine appears. Then advance the catheter another 1-2 inches to be sure the tip is fully inside the bladder before inflating the balloon. Do not force it if you meet resistance.
Your client's provider orders daily bladder irrigation to clear the urine of bacterial debris and blood clots. You follow protocol and attach a Y tube to the catheter and start bladder irrigation. The irrigant solution flows easily into the bladder, but shortly after you begin, the client reports lower abdominal pain and cramping. Which of the following actions should you take next? A. Slow the irrigant solution and continue the procedure. B. Stop the procedure and evaluate for an occlusion. C. Assure the client that some discomfort is expected with this procedure. D. Hasten the procedure by increasing the rate of flow of the irrigant.
B. Stop the procedure and evaluate for an occlusion. With this client's history and the possible development of clots, you should assess that the catheter has not become obstructed.
Which of the following clients should you manage first? A. The client with a spinal cord injury who has sediment in their urinary drainage bag. B. The client newly admitted to the unit after kidney surgery with bloody urine output. C. The client that is reporting pressure around their bladder. D. The client that is scheduled to be discharged home today with a leg bag.
B. The client newly admitted to the unit after kidney surgery with bloody urine output. Think ABCs of nursing. In this example, the postoperative client is at a risk for hemorrhage due to the possibility of intraoperative injury to the large vessels surrounding the kidney (aorta, inferior vena cava). Therefore, you should assess this client's bleeding first.
Which are functions of the colon? A. Lipid digestion B. Water absorption C. Protein absorption D. Vitamin absorption E. Facilitate stool passage
B. Water absorption D. Vitamin absorption E. Facilitate stool passage
When checking for jaundice, the nurse notes: A. White sclera B. Yellowish discoloration of the skin C. Pallor skin D. Tenderness in the left lower quadrant
B. Yellowish discoloration of the skin
Normal bowel sounds are: A. very high-pitched and more frequent than normal. They may occur with small bowel obstruction and inflammatory disorders. They indicate hyperperistalsis, which can result in diarrhea. B. high-pitched, with approximately 5-15 gurgles every minute. C. low-pitched, infrequent, and quiet. A decrease in bowel sounds indicate decreased peristalsis, which can result in constipation. D. If you hear no bowel sounds after listening in a quadrant for 3-5 minutes, you should listen in several areas before describing them as absent. Absent bowel sounds indicate a lack of intestinal activity, which may occur after abdominal surgery and may indicate a paralytic ileus.
B. high-pitched, with approximately 5-15 gurgles every minute.
Moderate head injury on the Glasgow Coma scale is a score of: A. 8 or less B: 9-12 C. 13-15
B: 9-12
A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? A. "Lean on the crutches to support your body weight when standing" B. "Fully extend your arms when holding onto the hand grips" C. "Hold the crutches on your unaffected side when preparing to sit in a chair." D. "Hold the crutches 9 inches in front of and to the side of each foot."
C. "Hold the crutches on your unaffected side when preparing to sit in a chair."
Which of the following responses should the nurse make when the client admits she is uncomfortable giving herself an enema? A. "It's a very simply procedure that people do at home all the time." B. "If you don't give yourself the enema, the provider cannot perform the procedure." C. "It appears that you are uncomfortable with administering yourself an enema."
C. "It appears that you are uncomfortable with administering yourself an enema." This is an example of the therapeutic communication technique of focusing on the client's feelings. It shows the client that you hear what they are saying to you, and you are willing to listen to their concerns. This response encourages the client ot continue to communicate freely.
How should the nursing assistant respond when you ask them to describe how they will place the client in Sims' position? A. "On the abdomen with a pillow positioned under the pelvis." B. "Lying on the right side with the knees drawn up to the chest." C. "On the left side turned toward the abdomen with the right leg drawn up."
C. "On the left side turned toward the abdomen with the right leg drawn up." Sims' position is lying semiprone on the left side. This is the correct procedure for administering an enema.
Which of these pulses are considered normal? A. +1 B. +4 C. +2 D. 0
C. +2
Which is the fluid of choice to correct isotonic dehydration? A. Dextrose 5% in 0.45% sodium chloride B. 0.45% sodium chloride C. 0.9% sodium chloride D. 3% sodium chloride
C. 0.9% sodium chloride This is an isotonic fluid that increases the intravascular supply. 0.45% is hypotonic, 3% is hypertonic.
Mild head injury on the Glasgow Coma scale is a score of:
C. 13-15
You inform the client that when administering enemas until clear, which of the following is the maximum number of enemas instilled without further instructions from the surgeon? A. 1 B. 2 C. 3
C. 3 Without further instruction from the prescribing provider, clients should receive no more than 3 consecutive enemas- otherwise, the client is at risk for fluid and electrolyte imbalances.
The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Choose all that apply. A. 5-6 inches B. 7-8 inches C. 3-4 inches D. 1-2 inches
C. 3-4 inches
The apical impulse is located at the: A. 2nd ICS right of the sternal border B. 5th ICS right of the sternal border C. 5th ICS left midclavicular line D. 4th ICS left of the sternal border
C. 5th ICS left midclavicular line Remember, the apical impulse is heard at the PMI.
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? A. 2.5cm to 3.75cm (1-1.5 in) B. 5cm to 7.5cm (2-3 in) C. 7.5cm to 10cm (3-4 in) D. 10cm to 12.5cm (4-5 in)
C. 7.5cm to 10cm (3-4 in)
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization. A. A client who has a persistent UTI. B. A client who has urge incontinence. C. A client who is in the ICU for a GI bleed. D. A client who has incontinence due to cognitive decline.
C. A client who is in the ICU for a GI bleed. The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.
Which piece of information is most important for the nurse to obtain prior to removing an indwelling urinary catheter? A. Date of insertion B. Type of catheter material C. Amount of saline in balloon D. Allergy to betadine or shellfish
C. Amount of saline in balloon The nurse would need to know the amount of saline inserted into the balloon prior to removing the catheter. This allows the nurse to use the correct syringe size and to ensure the nurse removes all of the saline before pulling the catheter out.
The nurse calculates urinary output for a client admitted with dehydration and determines the client's output is 800 mL/day. Which nursing intervention is most appropriate for the nurse to perform first? A. Notify the health-care provider. B. Document the finding as normal. C. Assess the urine color and clarity. D. Insert an indwelling urinary catheter
C. Assess the urine color and clarity. The nurse needs more information prior to notifying the health-care provider. Therefore, the nurse should assess the color and clarity of the urine first. The normal daily urine output should be a minimum of 1200mL.
A client reports severe abdominal pain. Which of the following nursing assessments should you perform? A. Obtain orthostatic blood pressures. B. Palpate bilateral pedal pulses. C. Auscultate and palpate the abdomen. D. Measure the client's jugular venous pressure.
C. Auscultate and palpate the abdomen. The client reports severe abdominal pain and may be hemorrhaging. For this client, the hemorrhage is most likely in the abdominal cavity where the surgery took place, so auscultate the abdomen immediately for decreased bowel sounds and palpate it for increased firmness and discomfort.
The nurse is assessing the urinalysis results for a client with an indwelling urinary catheter. Which findings indicate the presence of a urinary tract infection? Select all that apply. A. Glucose B. Ketones C. Bacteria D. Bilirubin E. Hemoglobin F. Leukocyte esterase
C. Bacteria E. Hemoglobin F. Leukocyte esterase
The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve (CN)? A. CN V B. CN VIII C. CN III D. CN X
C. CN III
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority? A. Have another nurse check the dose to be administered. B. Teach the client about possible adverse effects. C. Confirm the client's identity using two methods. D. Confirm that the client can swallow adequately.
C. Confirm the client's identity using two methods.
The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? A. Increased respiratory rate when the heart rate increases B. Decreased temperature after a period of diaphoresis C. Decreased blood pressure (BP) after standing up D. Increased heart rate after walking down the hall
C. Decreased blood pressure (BP) after standing up
When percussing the liver, the nurse expects to hear: A. Tympany B. Resonance C. Dullness D. Hyperosonance
C. Dullness
You are providing routine catheter care for a client 2 days after admission. As you start to cleanse the tissue surrounding the catheter, you note that the area is wet and erythematous. It appears that urine is leaking from around the catheter's insertion site. You also note some bladder distention. Which of the following actions should you take first? A. Deflate the balloon and remove the catheter. B. Call the provider and notify the charge nurse of your findings. C. Examine the catheter and the drainage tube along their entire path.
C. Examine the catheter and the drainage tube along their entire path. This is the least invasive action and you should do this first. The situation you encountered might very well be due to kinks or obstructions in the tubing. Examining the path of the urine from the client to the bag is a good way to check for this.
When obtaining a sterile urine specimen from an indwelling catheter, the nurse should do which of the following? A. Open the clamp at the bottom of the bag and fill a specimen cup B. Remove the indwelling catheter and have the patient urinate into a urinal C. Insert a needless syringe through a drainage port in the tubing
C. Insert a needless syringe through a drainage port in the tubing
A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A. Stretch the sheath portion of the condom catheter along the length of the penis. B. Secure the sheath portion with adhesive tape. C. Leave a space between the penis and sheath portion tip. D. Reposition the foreskin after application.
C. Leave a space between the penis and sheath portion tip. The nurse should leave a space of 2.5-5cm (1-2in.) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.
A student nurse enters the room of a client and begins the assessment while the registered nurse observes. Which action made by the student nurse requires correction by the registered nurse? A. Ask any visitors to leave the room B. Turn on the lights in the client's room C. Leave the door open to allow lighting D. Gather all supplies prior to entering the room.
C. Leave the door open to allow lighting The student nurse should close the door and/or pull the curtain around the client to PROVIDE PRIVACY.
Accentuated lumbar curve A. Kyphosis B. Scoliosis C. Lordosis
C. Lordosis
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Measure the client's vital signs. B. Notify the primary care provider. C. Lower the enema fluid container. D. Stop the enema instillation.
C. Lower the enema fluid container. Some abdominal cramping is to be expected during enema administration. To ease discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.
Which of the following actions should the nursing assistant take first if the client reports cramping? A. Place the client on the bedpan to evacuate the enema solution immediately. B. Remind the client that cramping can occur during enema administration. C. Lower the height of the solution bag to slow the instillation rate.
C. Lower the height of the solution bag to slow the instillation rate. This is the first action the nursing assistant should take. Some cramping is often experienced by clients receiving an enema, but the cramping should not be painful or severe. Lowering the height of the enema bag to slow the instillation rate of the solution is a simple initial action that will quickly lessen the client's cramping and promote their ability to receive and retain the enema solution.
Working on a cardiac floor, the nurse needs to review the correct procedure for taking a pulse. A. Check the brachial pulse 15 seconds then check the radial B. Auscultate the apical pulse for one full minute. C. Palpate the radial pulse and note rate, rhythm and force D. Palpate radial pulse note an irregular rhythm
C. Palpate the radial pulse and note rate, rhythm and force
Before replacing a condom catheter, which of the following nursing actions should you perform? A. Cleanse the glans penis with povidone-iodine. B. Apply bacitracin ointment to the meatus. C. Provide perineal care with soap and water.
C. Provide perineal care with soap and water. It is appropriate to perform perineal care while the condom catheter is off. Then, allow the area to dry, reapply the skin barrier, and attach a new condom catheter.
Which quadrant is the appendix located? A. RUQ B. LUQ C. RLQ D. LLQ
C. RLQ
Which test should the patient undergo when the Weber test result is positive? A. Snellen test B. Whisper test C. Rinne test D. Romberg test
C. Rinne test
Which of these heart sounds are abnormal? (select all that apply) A. S1 B. S2 C. S3 D. S4
C. S3 D. S4 S3: pregnant woman, kids, young adults & athletes. S4: Totally abnormal. Can indicate difficultly in atrial contractions. Occurs with severe left ventricular hypertrophy.
What is the expected normal finding when palpating the abdomen? A. Distended B. Pulsating C. Soft, nontender D. Tender
C. Soft, nontender
The nurse is testing the client's ability to recognize familiar objects. When the nurse places a coin in the client's hand, the client correctly identifies the object. How would the nurse document this finding? A. Apraxia B. Astereognosis C. Stereognosis D. Hyperesthesia
C. Stereognosis
The nurse palpates an enlarged, painful spleen. The next step is: A. Palpate deeply to find the splenic border B. Have the patient bear down C. Stop the splenic exam D. Palpate McBurny's point
C. Stop the splenic exam
The articulation of the mandible and the temporal bone is known as the: A. Condyle of the mandible B. Zygomatic arch of the temporal bone C. Temporomandibular joint D. Invertebral foramen
C. Temporomandibular joint
Which of the following clients should you manage first? A. The client who is 1 day postoperative and needs their indwelling catheter removed. B. The client with a condom catheter who reports pain each time he urinates. C. The client with dementia who pulled off his condom catheter D. The client with an indwelling urinary catheter who has green exudate seeping from the urethra.
C. The client with dementia who pulled off his condom catheter When a condom catheter is removed traumatically, tissue damage can result. Also a condom catheter can impair circulation to the penis if it is applied incorrectly (think ABCs), and that might be why the client removed it.
Which behavior by the nurse indicates the highest potential for spreading infections among clients? A. Disinfects dirty hands with antibacterial soap B. Rubs alcohol-based hand gel for 20-30 seconds C. Washes hinds primarily after leaving each room D. Follow guidelines for isolation precautions
C. Washes hinds primarily after leaving each room
The nurse enters the room of a client and, without the use of the stethoscope, can hear the client wheezing. How should the nurse document this finding in the medical record? A. Wheezes noted upon inspection B. Wheezes noted upon percussion C. Wheezes noted upon direct auscultation. D. Wheezes noted upon indirect auscultation.
C. Wheezes noted upon direct auscultation. When a nurse can hear wheezes without the use of a stethoscope, this is direct auscultation.
A nurse is auscultating a client's apical pulse to listen to the S1 and S2 heart sounds. S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. When the ventricular walls contract C. When the semilunar valves close D. As the mitral valve snaps open
C. When the semilunar valves close
Hypoactive bowel sounds are: A. very high-pitched and more frequent than normal. They may occur with small bowel obstruction and inflammatory disorders. They indicate hyperperistalsis, which can result in diarrhea. B. high-pitched, with approximately 5-15 gurgles every minute. C. low-pitched, infrequent, and quiet. A decrease in bowel sounds indicate decreased peristalsis, which can result in constipation. D. If you hear no bowel sounds after listening in a quadrant for 3-5 minutes, you should listen in several areas before describing them as absent. Absent bowel sounds indicate a lack of intestinal activity, which may occur after abdominal surgery and may indicate a paralytic ileus.
C. low-pitched, infrequent, and quiet. A decrease in bowel sounds indicate decreased peristalsis, which can result in constipation.
pleural rub
Caused by inflammation of the pleura; localized and a grating-like sound
crackles
Coarse or fine sound that is intermittent, nonmusical, and brief; it can often be heard with pneumonia or bronchitis
A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't survive to see my children grow up." Which response by the nurse best conveys concern and active listening? A. "You're strong and have youth on your side to fight the breast cancer." B. "There have been many advances in breast cancer treatment; hope for the best." C. "I'd be worried too; I've seen a lot of patients die of breast cancer." D. "Breast cancer is a serious disease; I can understand why you're worried."
D. "Breast cancer is a serious disease; I can understand why you're worried."
Which of the following would be an appropriate question to collect subjective data about a client's past health history? A. "Do you have any family members with liver disease?" B. "Have you noticed changes in your appetite or weight loss or gain?" C. "Do you have any painful or tender areas?" D. "Have you had any previous abdominal surgeries?"
D. "Have you had any previous abdominal surgeries?" This refers to the client's past health history.
After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment should be used. Which response by the nurse is best? A. "Why don't you see what your spouse thinks?" B. "What do you think about radiation therapy?" C. "If I were you, I'd go with chemotherapy." D. "I'll give you some information about each option."
D. "I'll give you some information about each option."
A male patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? A. "It's very important to take your blood pressure medication." B. "Why did you stop taking your high blood pressure medication?" C. "You're lucky you didn't have a stroke; you really need to take your medication." D. "Tell me more about your experience with your high blood pressure medication."
D. "Tell me more about your experience with your high blood pressure medication."
The nurse takes the patient's temperature and gets a reading of 38.5 degrees celsius. What is the patient's temperature in degrees fahrenheit? A. 98..6 B. 99.5 C. 100.4 D. 101.3
D. 101.3
Testicular cancer occurs most often in males around age: A. 65+ B. 50-65 C. 35-49 D. 15-34
D. 15-34
The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon? A. 3mL B. 5mL C. 10mL D. 30mL
D. 30mL
How long should a retention (oil) enema be retained for? A. 40min B. 20min C. 10min D. 30min
D. 30min
A patient presents to the emergency department with the following vital signs: temp 101.5, pulse 124, bp 145/88, respiratory rate 32, and pulse oximetry 88%. What is the nurse's priority action? A. Administer acetaminophen (Tylenol) for the temperature B. Administer antihypertensive medication for the blood pressure C. Offer the patient a tepid bath for the temperature D. Administer 2 L of oxygen via nasal cannula for the pulse oximetry
D. Administer 2 L of oxygen via nasal cannula for the pulse oximetry
What would you expect to find when assessing for a positive "clubbing" sign? A. Nail base firm and slightly tender B. Curved nails with convex profile and ridges C. Spongey nail base with angle of 140 degress D. Angle of nail base > 180 degrees and spongey
D. Angle of nail base > 180 degrees and spongey
A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? A. Urethral meatus B. Labia minora C. Perineum D. Anus
D. Anus The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from the area that is least contaminated to the area that is the most contaminated.
You are screening your patient for scoliosis. What finding supports a diagnosis of scoliosis? A. Cervical flexion B. Thoracic inversion C. Symmetry noted across the lumbar region D. Asymmetry across the ribs
D. Asymmetry across the ribs
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A. The duration of the procedure B. 10-15min C. Until the client feels the urge to defecate D. At least 30 min
D. At least 30 min The enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min.
Striking the sole of the foot elicits dorsiflexion of the big toe and fanning of the toes. This is known as: A. Achilles reflex B. Proprioception C. Ataxia D. Babinski response
D. Babinski response
A nurse obtains a HR of 56bmp which would mean: A. Tachycardia B. Arrhythmia C. Normal D. Bradycardia
D. Bradycardia. A normal HR is 60-100 bpm.
High-pitched swooshing sounds heard over the carotid artery on the right side is indicative of? A. Murmurs B. Systole C. Diastole D. Bruits
D. Bruits
Which term should the nurse use to describe a patient infected with a virus but who does not have any outward signs of the disease? A. Pathogen B. Fomite C. Vector D. Carrier
D. Carrier
A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A. Irrigate the catheter. B. Assess for peripheral edema. C. Palpate for bladder distention. D. Check the catheter for kinks.
D. Check the catheter for kinks. The nurse should identify that the output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed.
The nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen? A. Obtaining the specimen from the drainage bag B. Disconnecting the tubing and obtaining the specimen C. Inserting a new indwelling urinary catheter to obtain a sterile urine specimen D. Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically
D. Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically This ensures the specimen is sterile and not contaminated.
Which of the following findings on respiratory system palpation indicates an area of consolidation? A. Decreased crepitus B. Increased tactile fremitus C. Increased crepitus D. Decreased tactile fremitus
D. Decreased tactile fremitus
The appropriate method for auscultating an adult's apical pulse is to use the: A. Bell of the stethoscope, at the left 4th intercostal space, left sternal border. B. Diaphragm of the stethoscope, at the 2nd intercostal space, left sternal border. C. Bell of the stethoscope, at the 2nd intercostal space, right side of sternum. D. Diaphragm of the stethoscope, at the left 5th intercostal space, midclavicular line.
D. Diaphragm of the stethoscope, at the left 5th intercostal space, midclavicular line.
A nurse is reviewing a group of prescriptions. Which of the following should the nurse identify as an example of a complete prescription? A. Aspirin PO 1 tablet daily B. Ferrous sulfate 624mg PO C. Hydrocodone/acetaminophen 5/325 mg PRN D. Digoxin 1.25 mg PO daily
D. Digoxin 1.25 mg PO daily
Bronchovesicular breath sounds are best heard over which area? A. At the base of the lungs near the diaphragm B. Fifth ICS, mcl C. Midline over the trachea just below the larynx D. First and second intercostal spaces next to the sternum
D. First and second intercostal spaces next to the sternum
Which is a position of comfort for respiratory patients? A. Standing B. Supine C. Doral recumbent D. Fowlers
D. Fowlers
The nurse is removing personal protective equipment (PPE). Which item should be removed first? A. Gown B. Face shield C. Hair covering D. Gloves
D. Gloves
Which risk in a genogram suggests highest risk for cardiovascular disease? A. HTN in grandparents B. Diabetes mellitus in extended family C. Weight patterns in family D. Heart attack in father & sibling
D. Heart attack in father & sibling
Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? A. Hepatitis B B. Measles C. Meningitis D. Infectious diarrhea
D. Infectious diarrhea
A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? A. Prone B. Dorsal recumbent C. Right lateral with both knees at chest D. Left lateral with the right leg flexed.
D. Left lateral with the right leg flexed. The position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.
When there is no gurgling in the RLQ after one minute, what should the nurse do? A. Palpate for rigidity B. Inspect for symmetry C. Assess for dehydration D. Listen for five minutes
D. Listen for five minutes
This location is where the nurse would percuss to assess for appendicitis: A. Traube's space B. Left costal margin C. Anterior axillary line D. McBurney's point
D. McBurney's point
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A. Olecranon bursa B. Annular ligament C. Base of the radius D. Medial and lateral epicondyle
D. Medial and lateral epicondyle
After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which parameter would the nurse document as a 7/10? A. Emotional distress B. Pulse pressure C. Oxygen saturation D. Pain
D. Pain
Which of the following terms indicates that a medication is given via an injection? A. Enteral B. Sublingual C. Transdermal D. Parenteral
D. Parenteral
While the nurse is performing an admission assessment on a newly admitted client, the client states, "I am very unsteady on my feet." What assessment would the nurse perform to evaluate the client's statement? A. Test the client's intellectual functioning by asking the client to remember several sequences of numbers. B. Test ocular fields to see if there is a visual problem causing unsteadiness C. Assess the client for two point discrimination. D. Perform assessments to evaluate cerebellar function
D. Perform assessments to evaluate cerebellar function
How should the nurse dispose of a contaminated needle after administering an injection? A. Recap the needle, and place it in a puncture-proof container. B. Place the needle in a biohazard bag with other contaminated supplies. C. Recap the needle, and carefully place it in the trashcan. D. Place the needle in a specially marked, puncture-proof container.
D. Place the needle in a specially marked, puncture-proof container.
A Romberg test is performed. The nurse is testing: A. Convergence B. Sensitivity C. Accommodation D. Proprioception
D. Proprioception
A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess: A. Posture B. Activity tolerance C. Body mechanics D. ROM
D. ROM
The nurse notes that the patient's indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? A. Encourage fluids that will increase the urine acidity B. Notify the healthcare provider immediately C. Flush the catheter tubing with saline D. Replace the indwelling urinary catheter
D. Replace the indwelling urinary catheter
The client has a pulse oximeter reading of 91%, the nurse should implement which of the following measures first? A. Change the fingers the pulse ox is on B. Place the client on a nasal cannula C. Place the client on a simple face mask D. Sit the client up
D. Sit the client up
Which action by the nurse is a nonverbal behavior that enhances communication? A. Maintaining a distance of 6 to 12 inches B. Keeping a neutral expression on the face C. Asking mostly open-ended questions D. Sitting down to speak with the patient
D. Sitting down to speak with the patient
The nurse is performing an otoscopic examination on an adult patient. The nurse has the patient tilt head to the side not being examined. Which step should the nurse perform next? A. Test the mobility of the tympanic membrane B. Insert the speculum into the ear canal slowly C. gently pull the pinna down and back D. Straighten the ear canal by pulling the pinna up and back
D. Straighten the ear canal by pulling the pinna up and back
The nurse is caring for a client who is being discharged after sustaining a myocardial infarction. What is most important for the nurse to instruct the client? A. Consume a bland diet B. Use a salt substitute on foods C. Avoid consuming grapefruit and its juice D. Take stool softeners to prevent straining.
D. Take stool softeners to prevent straining. A client who has heart disease should never bear down to strain with bowel movements, as this can cause cardiac arrhythmias or cardiac arrest.
The nurse is unable to elicit a patellar reflex. What is the best action for the nurse to take next to try to test this reflex? A. Have the client lie on the left side B. Take no action; document hyporeflexia C. Reposition the client D. Use distraction to facilitate relaxation
D. Use distraction to facilitate relaxation
Resistance while the patient shrugs the shoulders is a test of which CN? A. II B. V C. IX D. XI
D. XI
Which of the following is NOT one of the ten rights of med admin? A. Right medication B. Right dose C. Right time D. Right documentation E. Right equipment
E. Right equipment
CN VII
Facial
True or false: bruits in the abdomen are normal.
False
When should you check the medication 3 times?
First check: read the MAR Second check: while preparing the medications (pouring) Third check: recheck the label on the container before returning to the storage place.
CN IX
Glossopharyngeal
bronchial sounds
Heard over the large airways in the anterior chest; more tubular and hollow sounding
stridor
High pitched and often barking in nature; suggests narrowing of the upper airways (larynx, trachea)
Place the lower extremities in the order that they should be assessed: -Knees -Ankles -Hips -Feet
Hips, Knees, Ankles, Feet
CN XII
Hypoglossal
Stages of infection
Incubation, prodromal, illness, decline, convalescence
What is the correct order of examination for the musculoskeletal system?
Inspection, Palpation, ROM
CN III, IV, VI
Involved with extraocular movement of the eye
wheeze
Musical, high pitched, inspiratory or expiratory; suggest narrowed airways; often heard with asthma
Endogenous healthcare related infection
Normal flora multiply and cause infection as a result of treatment
What are the 5 P's?
Pain, pallor, paresthesia, pulselessness, paralysis
supination
Palm up
Exogenous Healthcare-Related Infection
Pathogen acquired from healthcare environment
Donning
Putting PPE on (in alphabetical order)
rhonchi, stridor
Relatively low pitched and snoring like sound; suggests secretions in large airways
Doffing
Taking PPE off (feet --> head)
CN V
Trigeminal
CN IV
Trochlear
True or false? Guarding is an expected finding when palpating the abdomen.
True
CN X
Vagus
CN VIII
acoustic
Order of spinal sections:
cervical (7), thoracic (12), lumbar (5), sacral (5 fused)
S2 heart sound
closure of aortic and pulmonic valves, opening of mitral and tricuspid valves. higher in pitch and shorter duration
S1 heart sound:
closure of mitral and tricuspid valves, opening of aortic and pulmonic valves. lower in pitch and longer lasting
IM Sites
deltoid acromion, vastus laterus, ventrogluteal trochanter
pulse pressure
difference between systolic & diastolic pressures
The Glasgow Coma Scale is based on:
eye opening response, verbal response, motor response
nosocomial infection
hospital acquired infection
droplet precations
measures taken to prevent the spread of disease transmitted by small (greater than 5 microns) respiratory droplets from an infected person.
Contact precautions
measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens via direct or indirect contact
abduction
movement away from the midline
Adduction
movement toward the midline
CN III
oculomotor
CN 1
olfactory
CN II
optic
Pronation
palm down
10 rights:
patient, medication, time, date, route, pre-assessment, education, post-assessment, documentation, refusal
What position for inspecting neck and upper extremities?
sitting
CN XI
spinal accessory
What position for inspecting the spine?
standing
cardiac output
stroke volume x pulse (heart) rate
orthostasis
sudden drop of more than or equal to 10 mm Hg diastolic or drop in systolic BP of 20 or more mm Hg within 2-5 min of moving from a lying or sitting position to a standing position, causing dizziness and/or fainting
What position for inspecting lower extremities?
supine
what are the vital signs?
temperature, pulse, respiration, blood pressure, *pain, *health literacy
stroke volume
the quantity of blood pumped out by each contraction of the left ventricle
Inversion
turning inward
Eversion
turning outward
