Unit 2 Quiz

Which nurses' note includes judgmental language? A. 0800 found lying in stool. night shift never turns the patients B. 0800 male family member at beside states "you witches never take care of my mother" C. 0800 dried stool on left buttock D. 0800 family member at bedside swearing loudly at the nursing staff

A. 0800 found lying in stool. night shift never turns the patients

Which is a normal assessment finding during assessment of skin and nails? A. Capillary refill < 2 seconds B. Skin moist to touch C. Skin turgor > 3 seconds D. Dry scaly skin over bilateral lower extremities

A. Capillary refill < 2 seconds

Which condition is associated with clubbed nails? A. Chronic hypoxia B. Hypertension C. Increased cholesterol D. Normal finding with aging

A. Chronic hypoxia

When documenting client care, the nurse is aware to use abbreviations conscientiously and safely. What is included in the conscientious and safe use of abbreviations? A. Limiting abbreviations to those approved by the institution B. Using only abbreviations whose meaning is self-evident to educated health professionals C. Ensuring that abbreviations are understandable to clients who may seek access to their health records D. Use only those abbreviations that are defined in full in another location in the client's medical record

A. Limiting abbreviations to those approved by the institution

Which is true of wheezes? A. Occurs as air passes through narrow airways B. Can only be heard with a stethoscope C. Mild wheezing is heard on inspiration D. Are always monophonic

A. Occurs as air passes through narrow airways

Which provides the best description of vesicular breath sounds? A. Soft, low pitched sounds B. Low, harsh sounds C. Inspiratory phase is shorter than expiratory phase D. Heard over the major airways

A. Soft, low pitched sounds

What is essential in using charting by exception (CBE) as the documentation method? A. all nurses and health care workers use identical definitions of normal data. B. Consistent documentation forms. C. Charting in black ink only. D. This method does not have any essential requirements.

A. all nurses and health care workers use identical definitions of normal data.

The nurse is assessing a newly admitted client. Which finding would the nurse immediately report to the healthcare provider (HCP)? A. Auscultation of vesicular breath sounds over the lung bases B. Auscultation of a bruit over the right carotid artery C. Decreased muscle strength in both arms D. Auscultation of S1 and S2 when counting apical pulse

B. Auscultation of a bruit over the right carotid artery

Which condition may present with absent or diminished breath sounds? A. Early CHF B. COPD C. Pneumonia D. Pleurisy

B. COPD

The nurse palpates a grating sensation over the temporomandibular joint during movement. What is this grating sensation called? A. Inflammation B. Crepitus C. Fremitus D. Arthritis

B. Crepitus

When auscultating breath sounds, apical pulse, or bowel sounds, it is appropriate for the nurse to listen over the client's gown to protect the client's privacy? A. True B. False

B. False

Which assessment technique is used in assessing the client's radial pulse? A. Percussion B. Palpation C. Auscultation D. Inspection

B. Palpation

Which assessment finding is collected using light palpation? A. Thrill B. Tenderness C. Renal colic D. Liver size

B. Tenderness

The nurse is documenting about a client's ambulation attempt. Which is the best documentation of this attempt? A. ambulated to the nurses' station with assistance. Verbalized shortness of breath with ambulation B. Ambulated in hall with assistance C. Ambulated 15 feet with stand-by attempt, RR= 26, O2 sat 92% during ambulation D. Ambulated 15 feet with assistance. Skin color cyanotic with ambulation

C. Ambulated 15 feet with stand-by attempt, RR= 26, O2 sat 92% during ambulation

Which health screening is expected for women between 45 and 54 years of age? A. Skin inspection by dermatologist every 3 years. B. Annual colonoscopy C. Annual mammograms D. Annual fecal occult blood test

C. Annual mammograms

Which is not a focus of nursing assessment? A. Client's coping to stress B. Physical response to illness C. Disease pathology D. Client's functional abilities

C. Disease pathology

The nurse has made an error in documentation. What is the accepted method of correcting errors in a handwritten nurse's note? A. Thoroughly obliterate the incorrect entry, then document the correct information. B. Use white out to remove the incorrect entry, then document the correct information. C. Draw a single line through the incorrect entry, followed by your initials, then document the correct information. D. Draw a single line through the incorrect entry, followed by the word "error", then document the correct information.

C. Draw a single line through the incorrect entry, followed by your initials, then document the correct information.

The nurse is inspecting a postoperative incision site for infection. What type of assessment is the nurse performing? A. Complete B. Time-lapsed C. General D. Focused

C. General

After performing a dressing change, the nurse documents that the incision was well approximated with purulent drainage present. Which phase of the nursing process is demonstrated in this documentation? A. Evaluation B. Planning C. Intervention D. Assessment

C. Intervention

Which test on a CBS affects blood clotting? A. Hematocrit B. Hemoglobin C. Platelets D. White blood cells

C. Platelets

Which assessment is not included in the general survey? A. Skin color B. Posture C. Tenderness D. Hygiene practices

C. Tenderness

Which is true of adventitious breath sounds? A. Heard primarily on inspiration B. Always heard on both inspiration and expiration C. Soft, breezy, low-pitched sounds D. Abnormal sounds heard over normal breath sounds

D. Abnormal sounds heard over normal breath sounds

Which best describes bronchovesicular breath sounds? A. Soft, breezy sounds B. Fine, crackling sound heard on inspiration C. High-pitched squeaking sound D. Heard distal to the manubrium

D. Heard distal to the manubrium

What is the correct order of assessment for adults? A. Auscultation, Inspection, Palpation, Percussion B. Palpation, Auscultation, Inspection, Percussion C. Percussion, Palpation, Auscultation, Inspection D. Inspection, Palpation, percussion, Auscultation

D. Inspection, Palpation, percussion, Auscultation

What is the best assessment of strength prior to getting a patient out of bed? A. Dangle the patient on the side of the bed for a few minutes prior to weight bearing. B. Assess pulse rates and BP prior to getting the patient out of bed. C. Instruct the patient to lift both arms as you press down with resistance. D. Instruct the patient to lift each leg as you press down with resistance

D. Instruct the patient to lift each leg as you press down with resistance.