Passpoint - Basic Physical Assessment

Which trait is the most important for ensuring that a nurse-manager is effective? Time management skills Communication skills Clinical abilities Health care experience

Communication skills

The nurse-manager has posted shift assignments on the unit. Which duty should the licensed practical nurse (LPN) refuse? Performing a sterile dressing change Flushing a nasogastric tube Administering oral medications Conducting the admission assessment on a new client

Conducting the admission assessment on a new client

A client who was brought to the emergency department after a motor vehicle crash is reporting abdominal pain. Which finding would the nurse report prior to the health care provider performing peritoneal lavage? Unconscious client History of abdominal surgery Allergy to radiopaque dye Distended bladder

Distended bladder

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? "Checking both carotid arteries at the same time may impair cerebral circulation." "Checking both carotid arteries at the same time may cause transient hypertension." "The pulse can't be checked accurately if the arteries are palpated at the same time." "Checking both carotid arteries at the same time may cause severe tachycardia."

"Checking both carotid arteries at the same time may impair cerebral circulation."

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response? "Lying down and crying can cause the fontanels to bulge." "The mother will have less trouble holding a quiet, upright infant." "The infant can breathe more easily when sitting up." "Lying down can cause the fontanels to recede, making assessment more difficult."

"Lying down and crying can cause the fontanels to bulge."

A client performs monthly self-breast examinations. Which finding should the client promptly report? Multiple tender, round masses in both breasts Areolae that are bilaterally darkened in color Freely movable masses that become tender before menses A hard, nontender mass in the upper outer quadrant of the left breast

A hard, nontender mass in the upper outer quadrant of the left breast

The emergency department nurse obtains laboratory test results for a newly admitted client. Which result should she report to the physician immediately? Creatinine level of 1.1 mg/dl Alkaline phosphatase level of 70 IU/ml Alanine aminotransferase level of 45 IU/L Cardiac troponin I level of 3.0 mcg/L

Cardiac troponin I level of 3.0 mcg/L

A nurse is discussing skin turgor evaluation of an elderly client with her peers. While doing so, the nurse should include which information with her colleagues? Inelastic skin turgor is a normal part of aging. Dehydration causes the skin to appear edematous and spongy. Overhydration causes the skin to tent. Normal skin turgor is moist and boggy

Inelastic skin turgor is a normal part of aging.

The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap? Take blood pressure readings in both arms. Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable. Have the client lie down while taking his or her blood pressure. Inflate the cuff to at least 200 mm Hg.

Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.

A nurse provides care for a client who developed hives after having an allergic reaction to strawberries. Which finding indicates to the nurse that the client has experienced improvement of symptoms? Itching is relieved. Erythema decreases. The rash improves. The pain of the rash subsides.

Itching is relieved.

The nurse is assisting with the care of a neonate born to a mother with type 1 diabetes. When gathering data on the neonate, the nurse would suspect that the neonate is experiencing hypoglycemia based on which finding? Jaundice Bradycardia Peripheral acrocyanosis Lethargy

Lethargy

A nurse is collecting data on a 47-year-old client who has come to the health care provider's office for an annual physical examination. Which finding indicates normal changes associated with aging in this client? more frequent aches and pains increased loss of muscle tone accepting physical limitations failing eyesight, especially close vision

failing eyesight, especially close vision

A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require? Monitoring of arterial oxygen saturation (SaO2) Chest auscultation Arterial blood gas (ABG) studies A chest X-ray

A chest X-ray

A nurse is performing a head-to-toe assessment. Which part of the hand should the nurse use to evaluate this client's body for warmth? Finger pads Ulnar surface Dorsal surface Fingertips

Dorsal surface

While caring for a client in labor, the nurse obtains data that suggests that the fetus may be in distress. Which finding would the nurse report to the supervising registered nurse? fetal blood pH less than 7.20 early decelerations in fetal heart rate during contractions an increase in fetal heart rate with fetal scalp stimulation lack of meconium staining

fetal blood pH less than 7.20

A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage? weak, irregular pulse; cool, moist skin; and hypotension restlessness, confusion, increased urine output, and warm, dry skin cyanosis, nausea, vomiting, and constricted pupils even, unlabored respirations; tachycardia; and hemoptysis

weak, irregular pulse; cool, moist skin; and hypotension

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: insert an oral airway. position the client on his side. withhold food and fluids. insert a nasogastric (NG) tube.

withhold food and fluids.

The newly-hired nurse is monitoring a client for adverse reactions during barbiturate therapy. The nurse preceptor asks what is the major disadvantage of barbiturate use. What is the best response by the newly-hired nurse? "There is a potential for drug dependence with barbiturates." "Barbiturates have a prolonged half-life." "There is a potential for hepatotoxicity with barbiturates." "There is poor absorption of the barbiturate."

"There is a potential for drug dependence with barbiturates."

A nurse is caring for a client with myasthenia gravis. What data should the nurse collect to monitor for the complications of myasthenia gravis? Respiratory status Pain rating Allergy history Circulatory status

Respiratory status

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: match the room temperature with the client's body temperature. maintain room temperature at 78° F (25.6° C). keep the client warm. keep the client uncovered.

keep the client warm.

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? "The stoma should remain swollen distal to the abdomen." "At first, the stoma may bleed slightly when touched." "A burning sensation under the stoma faceplate is normal." "The stoma should appear dark and have a bluish hue."

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

An adolescent female arrives in the emergency department after a physical assault. The suspected attacker was also brought to the hospital for treatment of injuries. A male health care provider is assigned to examine the client. Which action would best protect the client's rights during the physical examination? Leave the door open so that other staff can observe the interaction. Keep the client's friends informed of her medical condition. Place the suspected attacker in the examination room next to the client. Arrange for a female health care worker to be present.

Arrange for a female health care worker to be present.

Which finding should the nurse expect to observe in a client with cholelithiasis who is experiencing obstructive jaundice? Clay-colored stools Reduced hematocrit Straw-colored urine Elevated urobilinogen in the urine

Clay-colored stools

The nursing instructor is demonstrating a head-to-toe assessment. Which plane would the instructor use to divide the body longitudinally into anterior and posterior regions? Frontal plane Transverse plane Sagittal plane Midsagittal plane

Frontal plane

A client reports abdominal pain. During her focused assessment, which action would the nurse implement to aid in her investigation of this complaint? Checking for warmth in the painful area Using deep palpation Palpating the painful area last Palpating the painful area first

Palpating the painful area last

A client requests something to treat his constipation. The client's medication administration record contains an order for a laxative to be administered every other day as needed. Which assessment finding by the licensed practical nurse indicates the need to notify the registered nurse (RN) before administering the laxative? Presence of blood in the client's stool Abdominal distention Incontinence of liquid stool Complaints of abdominal fullness

Presence of blood in the client's stool

The nurse is working in a public health clinic. Four clients present with various skin disorders. Which disorder requires disclosure to public health officials?

REDNESS ON BACK Picture is a rubella (German measles) rash. Rubella is a contagious viral infection known for its distinctive red rash. Because of vaccines, it is not seen often but is still classified as a communicable disease. Titers are drawn to document immunity.

The nurse monitoring a client's pulse notes that it is easily palpable at 84 beats/minute and regular. Which term would the nurse use in charting the pulse assessment? Dysrhythmia Bradycardia Regular Tachycardia

Regular

The vital signs of a client are temperature, 98.6 F (37 C) orally; pulse, 80 beats/minute; and respirations, 30 breaths/minute. Which interpretation of these values is correct? Temperature is above the normal range. Pulse is above the normal range. Respirations and pulse are above the normal range. Respirations are above the normal range.

Respirations are above the normal range.

A nurse reports to a disaster site with multiple victims to conduct a primary survey. Which nursing intervention is considered a primary survey? Removing client's clothing Taking blood pressure Performing a complete health history and physical examination Identifying family members

Taking blood pressure

A nurse is explaining the Snellen Chart to a group of nursing students. Which statement about a client with 20/40 vision would the nurse include in her explanation? The client can read from 20' (6 m) what a person with normal vision can read from 40'. The client can read at 30' (9 m) what a person with normal vision can read from 40'. The client can read the vision chart from 20' with the right eye and from 40' with the left eye. The client can read the entire vision chart from 40' (12 m).

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

A nurse is using the Glasgow Coma Scale (GCS) to help determine a client's level of consciousness (LOC). Based on a calculated score on the GCS of 10, what conclusion does the nurse draw? The client has a decreased LOC but is not in a deep coma. The client is in a deep coma with a poor prognosis. The client is alert and oriented but minimally impaired. The client has scored the highest possible score and has no impairment.

The client has a decreased LOC but is not in a deep coma.

A client reports abdominal pain. When examining this client, when should the nurse collect data? Any quadrant first The symptomatic quadrant first The symptomatic quadrant last The symptomatic quadrant either second or third

The symptomatic quadrant last

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim? A foreign object Saliva or mucus The tongue Edema

The tongue

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary? To ensure that the child can't consciously raise or lower the heart rate To obtain a heart rate that isn't affected by medication To eliminate interference from the jerky movements of chorea To compensate for the effects of activity on the heart rate

To compensate for the effects of activity on the heart rate

The nurse is obtaining data regarding a client's deep tendon reflexes. Which graphic shows the nurse assessing the biceps reflex?

To test the biceps reflex, the client's elbow is flexed at a 45° angle. The nurse places her thumb or index finger over the biceps tendon and strikes the digit with the pointed end of the reflex hammer, watching and feeling for the contraction of the biceps muscle and flexion of the forearm.

While obtaining data on a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen?

UNDER RIBS

The nurse is caring for a client with peripheral vascular disease. When palpating for the dorsalis pedis pulse, where should the nurse's fingers be placed for location of the pulse?

VEIN Dorsalis pedis should be palpated by using two fingers, the index and middle fingers of the dominant hand.

A client has just undergone a bronchoscopy. Which priority nursing intervention will the nurse perform at this time? recognizing personality changes checking level of consciousness (LOC) checking airway patency evaluating intellectual ability

checking airway patency

A nurse is caring for a client who has undergone a cystoscopy to diagnose bladder cancer. After the procedure, which signs should alert the nurse to a potential complication? dizziness and fainting urinary frequency and burning on urination chills and tachycardia pink-tinged urine and bladder spasms

chills and tachycardia

A nurse is collecting data on a school-age child who has just had a tonsillectomy. Which observation by the nurse would suggest postoperative hemorrhage? frequent swallowing decreased pulse rate dark brown emesis refusal of oral fluids

frequent swallowing

A client is diagnosed with otitis externa. Which finding should the nurse anticipate during data collection? symptoms of an upper respiratory infection erythema of the ear canal accompanied by a high fever pain that occurs when the pinna of the ear is pulled history of using cotton-tipped applicators to clean the ear

pain that occurs when the pinna of the ear is pulled

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 each other. halfway between the tonsillar pillar and the uvula. barely visible outside the tonsillar pillar. touching the uvula.

touching the uvula.

The nurse correctly identifies which as belonging to the dorsal cavity? vertebral canal mediastinum mouth reproductive organs

vertebral canal

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. The client inquires about Cheyne-Stokes respirations. What information would the nurse include in her explanation? "Cheyne-Stokes shallow breaths with an increased respiratory rate." "They are rapid, deep breaths with abrupt pauses between each breath." "Cheyne-Stokes are rapid, deep breaths and irregular breathing without pauses." "They are progressively deeper breaths followed by shallower breaths with apneic periods."

"They are progressively deeper breaths followed by shallower breaths with apneic periods."

The nurse is collecting data from a client with a rash on the chest and upper arms. Which questions should the nurse ask to obtain more information about the client's rash? Select all that apply. "What have you been using to treat the rash?" "Have you traveled outside the country?" "Are you allergic to any medications, foods, or pollen?" "How old are you?" "Do you smoke cigarettes or drink alcohol?" "When did the rash start?"

"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What have you been using to treat the rash?" "Have you traveled outside the country?"

A client sustained burns to the entire back and left arm. Using the Rule of Nines, calculate the percentage of burns on this client's body. 36% 18% 27% 9%

27%

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature? 38.9° C 39° C 40.1° C 47° C

38.9° C

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that further visual evaluation is needed? 9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart 15-year-old with 20/20 vision in both eyes 6-month-old infant who fixes on an object and whose head moves and eyes follow the object 4-year-old with 20/40 vision in both eyes

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart

Which method is best when approaching a 2-year-old child to listen to breath sounds? Tell the child it's time to listen to the lungs now. Tell the child to lie down while the nurse listens to the lungs. Ask the child if the child would like the nurse to listen to the front or the back of the chest first. Ask the caregiver to wait outside while the nurse listens to the lungs.

Ask the child if the child would like the nurse to listen to the front or the back of the chest first.

A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for gathering abdominal data. Use all of the options. 1 Perform light palpation. 2 Percuss the client's abdomen. 3 Ask the client to urinate. 4 Auscultate the client's abdomen. 5 Inspect the client's abdomen

Ask the client to urinate. Inspect the client's abdomen. Auscultate the client's abdomen. Percuss the client's abdomen. Perform light palpation.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority? Complete the client's registration information, perform an electrocardiogram (ECG), gain I.V. access, and take vital signs. Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin. Gain IV access, give sublingual nitroglycerin and a dose of aspirin, and alert the cardiac catheterization team. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the primary care provider.

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

Which is the highest priority performed by the nurse prior to completing this nursing action? Place the client in the supine position. Assess stomach residual. Assess bowel sounds. Flush tube with 100 ml of water.

Assess stomach residual.

An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client? Radial Carotid Brachial Femoral

Carotid

A nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When evaluating the client's pulse rate, what should the nurse remember? Count the apical or radial pulse for 60 seconds. Count the apical pulse only. Count for 15 seconds and multiply by 4. Always count for 30 seconds and multiply by 2.

Count the apical or radial pulse for 60 seconds.

A client with type 1 diabetes has a leg infection that is being treated with antibiotics, wet-to-dry dressings, and whirlpool therapy. Since the infection began, the client's blood glucose levels have been unstable. Which data collected by the nurse indicate a serious complication? Flushed cheeks, dry mouth, and acetone breath odor Mental changes, fever, and hand tremors Headache, sweating, and nervousness Periods of rapid breathing followed by absence of breathing, picking at the bed linens, and nausea

Flushed cheeks, dry mouth, and acetone breath odor

The nurse is caring for a client who states an increase in dyspnea. Which intervention would the nurse perform first?

PULSE OX READING Assessment is the first step in the nursing process/data collection. Assessing the pulse oximeter reading provides valuable information on the client's condition. Once the information is known, obtaining a breathing treatment or applying an oxygenated face mask, especially for a pulse oximeter reading under 90%, is appropriate. Health care provider notification would also be necessary because oxygen is a medication requiring an order.

A nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a patient-controlled analgesia pump. Which finding indicates that the client is obtaining adequate pain relief? Regular respirations of 10 breaths/minute Reports of itching of the abdomen Pain rating of 2 or 3 on a scale of 0 to 10 Waking frequently to push the re-dose button

Pain rating of 2 or 3 on a scale of 0 to 10

A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next? Swab the back of the tongue, then the tonsillar areas from side to side. Swab the tonsillar areas from side to side, avoiding inflamed areas. Swab the tonsillar areas from top to bottom. Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.

Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation will the nurse document that indicates the client tolerated the activity without distress? The client's pulse and respiratory rates increased moderately during ambulation. The client reported feeling dizzy and weak and perspired profusely. The client's head was down, with gaze cast down and toes were pointed outward. The client took small steps at a rate of 40 to 50 per minute.

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

The nurse is gathering vital signs on a client. Blood pressure reading is 180/100 mm Hg by electronic blood pressure cuff. Place in order the steps that should be taken. 1 Notify the RN. 2 Wait 5 minutes. 3 Perform a manual blood pressure. 4 Notify the health care provider.

Wait 5 minutes. Perform a manual blood pressure. Notify the RN. Notify the health care provider.

When assessing pain in a 5-year-old verbal child, which appropriate pain scale would the nurse use? FLACC Pain Scale Pain Distress Scale Wong-Baker Faces Pain Scale Pain Intensity Scale

Wong-Baker Faces Pain Scale

The nurse prepares to measure a client's blood pressure. What correct procedure for measuring blood pressure would the nurse utilize? Measuring the arm about 2" (5 cm) above the antecubital space Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference Using a bladder that is 6" (15 cm) long

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

A nurse is assigned to care for a group of clients following a motor vehicle accident. Which client should the nurse see first? a client with fracture of the radius and ulna a client with penetrating chest injury and difficulty breathing a client with right ankle sprain and rashes a client with facial injury and abdominal pain

a client with penetrating chest injury and difficulty breathing

The nurse-manager asks a newly hired LPN if the facility's rules of ethical conduct are understood. Which statement by the LPN indicates the need for further education? "I maintain client confidentiality at all times." "I'll support the Patient Care Partnership." "I make sure that I do everything in my client's best interest." "I don't discuss advance directives unless the client initiates the conversation."

"I don't discuss advance directives unless the client initiates the conversation."

A nurse reinforces home care instructions to a client who is being seen in the clinic for bacterial conjunctivitis of the right eye. Which client statement indicates an understanding of the instructions? "I should use good hand washing to help to reduce the spread of this infection to others." "I can use over-the-counter eye drops to control the eye discharge and the redness." "I can stop the antibiotics drops when my eyes no longer have purulent drainage." "A moist wash cloth should be used to remove drainage from my eyes each morning."

"I should use good hand washing to help to reduce the spread of this infection to others."

The nurse is collecting data on a client before surgery. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications? "I had an operation 2 years ago, and I don't want to have another one." "I haven't been able to eat anything solid for the past 2 days." "I've never had surgery before." "I've cut my smoking down from two packs to one pack per day."

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

A client comes to the clinic for diagnostic allergy testing. The client asks why is an intradermal injection used for this testing. How would the nurse best respond? "Intradermal drugs diffuse rapidly." "An intradermal injection is less painful." "Intradermal drugs diffuse slowly." "Intradermal drugs are easier to administer."

"Intradermal drugs diffuse slowly."

An elderly client is scheduled for discharge from the hospital. Which statement by the client indicates that further teaching is needed? "My daughter just recently waxed my hardwood floors." "I don't have any stairs in my home." "My daughter keeps my house clean and puts things away for me." "I just had new carpet installed in my living room."

"My daughter just recently waxed my hardwood floors."

The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation? "S1 and S2 sound fainter at the base." "S1 and S2 sound equally loud over the entire cardiac area." "S1 and S2 sound fainter at the apex." "S1 is loudest at the apex, and S2 is loudest at the base."

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

The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond? "The client's body is supine." "The client's body is facing backward." "The client's palms are turned forward." "The client's arms are elevated at shoulder level."

"The client's palms are turned forward."

A nurse is providing information to a client about the ear canal. What information would the nurse include? "The ear canal of an adult is horizontal." "The ear canal of an adult slants backward." "The ear canal of an adult slants upward." "The ear canal of an adult slants downward."

"The ear canal of an adult slants downward."

A client with a spontaneous pneumothorax has a chest tube connected to a drainage system and suction. Which situation does the nurse identify could cause a problem in proper functioning of the chest tube drainage system? Bubbling in the suction chamber Keeping the chest drainage system at floor level Blood clots in the drainage tubing Fluctuating levels in the underwater seal chamber

Blood clots in the drainage tubing

The health care team is performing cardiac compressions on an adult client. To assess the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR), the nurse palpates which pulse site on this client? Brachial Radial Apical Carotid

Carotid

A nurse participating in planning care for a client who is in labor expects to monitor the client's blood pressure frequently. Why is this action important? Decreased blood pressure is a sign of maternal pain. Blood pressure decreases at the peak of each contraction. Decreased blood pressure is the first sign of preeclampsia. Alterations in cardiovascular function affect the fetus.

Alterations in cardiovascular function affect the fetus.

A nurse obtains the following data from a client who just gave birth: blood pressure, 110/70 mm Hg; pulse, 60 beats/minute; respirations, 16 breaths/minute; lochia, moderate rubra; fundus, above the umbilicus to the right; and negative Homans sign. Which intervention is correct? No action is required since findings are normal. Turn the client on her left side to decrease the blood pressure. Ask the client to void, and recheck the fundus. Massage the fundus to decrease lochia flow and prevent hemorrhage.

Ask the client to void, and recheck the fundus.

The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? Because the nurse's touch may calm the child Because the nurse's touch may frighten the child Because the nurse's hand or stethoscope may feel cold, making the child recoil Because the child may cry as data collection proceeds, making auscultation difficult

Because the child may cry as data collection proceeds, making auscultation difficult

A nurse is reviewing a client's chart. Which documentation does the nurse expect to find to indicate that the client's reaction is a normal response to a corneal sensitivity test? Seeing a flash of light Pupil dilation Pupil contraction Blinking

Blinking

A nurse is gathering data on a client following an appendectomy. The blood pressure is 90/58 mmHg, and the apical pulse is 108. What is the appropriate action by the nurse? Notify the primary RN of assessment findings. Check the IV site for infiltration. Assess the dressing for bleeding. Document the finding and continue to monitor the client.

Assess the dressing for bleeding.

The nurse is caring for a client who had a bronchoscopy performed 60 minutes ago. The client reports being thirsty and requests a drink of water. What is the priority intervention by the nurse? Withhold food or fluids for 4 hours after the procedure. Administer metoclopramide 10 mg I.V. Give the client water. Assess the gag reflex.

Assess the gag reflex.

A nurse is obtaining data from a client reporting fatigue. When palpating lymph nodes, in which location would the nurse palpate the occipital lymph nodes?

BEHIND EAR Lymph nodes are part of the lymphatic system. Lymph nodes vary in size depending upon the body status. There are clusters of head and neck lymph nodes. Using the pads of the fingers, the nurse should palpate the area behind the ears bilaterally to assess the occipital lymph nodes.

A nurse is instructing a female client on the proper hygiene of wiping after toileting from front to back in order to prevent contamination of the urethra. At which location of the genitourinary tract is it most likely to establish an infection from improper hygiene?

BLADDER Because of the structure of the female genitourinary tract, bacteria causing infection can be introduced into the urethra and travel to the bladder to cause a bladder infection. One cause of a bladder infection is improper hygiene during toileting. Keeping the perineum as clean as possible diminishes the possibility of bladder infections due to contamination.

The nurse is obtaining orthostatic blood pressure (BP) readings for a client who states having dizziness. Vital signs are 152/86 mm Hg while sitting. Which BP results are essential to report to the health care provider? BP 142/78 mm Hg while standing BP 162/90 mm Hg while sitting BP 148/80 mm Hg while sitting BP 130/62 mm Hg while standing

BP 130/62 mm Hg while standing

A client is at risk for the development of hypovolemic shock after a prostatectomy. Which vital sign indicates that the client may be developing postoperative shock? BP 130/92, heart rate 56 BP 160/84, heart rate 72 BP 100/68, heart rate 84 BP 86/50, heart rate 102

BP 86/50, heart rate 102

A licensed practical nurse (LPN) who typically works on a medical-surgical unit is being cross-trained to work with postpartum clients. The nurse-manager is busy with a client who is giving birth and assigns the LPN to stock client rooms. Entering a client's room, the LPN notices that the client looks pale and shaky. Which action should the LPN take? Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager. Stop stocking the room, and inform the nurse-manager that the client needs to be evaluated by a registered nurse. Quickly finish stocking the room and tell the client to press the call button for a regular staff nurse. Find another LPN to help evaluate the client and confirm the observations.

Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager.

A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform? Perform an electroencephalogram. Perform an electrocardiogram. Administer naloxone. Check the glucose level.

Check the glucose level.

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. How will the nurse document his findings about this client's vesicle? Circumscribed, elevated, and filled with serous fluid Flat, nonpalpable, and colored Solid, elevated, and circumscribed Elevated, pus-filled, and circumscribed

Circumscribed, elevated, and filled with serous fluid

A nurse is testing a client's pupils for accommodation. Which findings should the nurse interpret as normal? Constriction and divergence Constriction and convergence Dilation and divergence Dilation and convergence

Constriction and convergence

A parent brings a 15-month-old child to the ambulatory care clinic for well-child care. The child is crying and pulling at the left ear, which appears erythematous. Which action should the nurse take first? Examine the ear with the child supine because this aids in visualizing the tympanic membrane. Examine the left ear first in order to evaluate what may be physically wrong with the child. Ask the parent to leave the room because parental anxiety is increasing the child's distress. Examine the affected ear last in order to minimize distress early in the exam.

Examine the affected ear last in order to minimize distress early in the exam.

An elderly client tells the nurse that he doesn't want to take a bath. Which action by the nurse is most appropriate? Calling the client's family and asking them to bathe him Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him bathe Documenting in the client's chart that he refused to bathe Calling the physician and telling him that the client is noncompliant with his care

Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him bathe

A client has a colostomy in the descending colon after surgical removal of a tumor. What type of stool should the nurse anticipate when the client resumes a regular diet? Formed, soft stools Hard stool with considerable flatus Liquid stools Mushy, semiliquid stools

Formed, soft stools

All of the following components may be part of a client's medical record. When reviewing the client's chart, which will the nurse identify as the major source of subjective data about the client's health status? Health history Physical findings Laboratory test results Radiologic findings

Health history

A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh? Lower diastolic blood pressure reading Higher diastolic blood pressure reading Lower systolic blood pressure reading Higher systolic blood pressure reading

Higher systolic blood pressure reading

A nurse is preparing to perform an abdominal assessment. Which sequence would the nurse follow to effectively perform an abdominal examination on a client? Inspection, auscultation, palpation, and percussion Inspection, palpation, percussion, and auscultation Inspection, percussion, palpation, and auscultation Inspection, auscultation, percussion, and palpation

Inspection, auscultation, percussion, and palpation

A 76-year-old client with no debilitating conditions belongs to which geriatric population? Middle-old Young-old Old-old Frail elderly

Middle-old

An older adult client has a history of aortic valve stenosis. Identify the area where the nurse should place the stethoscope to best hear the murmur.

OPPOSITE AREA OF HEART Aortic stenosis occurs from a constriction that restricts blood flow through the heart and causes the left ventricle to enlarge. This enlargement can lead to heart failure and development of life-threatening irregular heartbeats. The murmur of aortic stenosis is low-pitched, rough, and rasping. It is heard best in the second intercostal space, to the right of the sternum.

A client arrives to the emergency department with suspected appendicitis. The admitting nurse gathers data. Order the following steps according to the sequence in which they are gathered. Use all of the options. 1 Gently palpate all four quadrants, saving the painful area for last. 2 Percuss all four abdominal quadrants. 3 Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. 4 Obtain a health history. 5 Auscultate bowel sounds in all four quadrants.

Obtain a health history. Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. Auscultate bowel sounds in all four quadrants. Percuss all four abdominal quadrants. Gently palpate all four quadrants, saving the painful area for last.

A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Assess bowel sounds and abdominal tenderness. Document history of the symptoms. Insert an NG tube and connect to suction. Obtain vital signs.

Obtain vital signs.

A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Obtain vital signs. Document history of the symptoms. Insert an NG tube and connect to suction. Assess bowel sounds and abdominal tenderness.

Obtain vital signs.

The nurse mentor is observing a newly hired nurse while she performs a head-to-toe assessment. The mentor knows the newly hired nurse is effective in evaluating a client's posterior tibial pulse when she palpates which area? On the inner aspect of the ankle, below the medial malleolus Along the top of the foot, over the instep Medially in the antecubital space Midway between the superior iliac spine and symphysis pubis

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

While assisting a health care provider perform a musculoskeletal assessment on a client, the nurse asks the client to perform supination. Which graphic depicts a joint in supination?

PALM FACED UPWARDS Supination means to turn upward, and the first graphic (A) correctly shows the palm of the hand turned upward in supination. The second graphic (B) shows pronation, which means to turn downward as in the downward turn of the palm. The third graphic (C) shows eversion, which is the turning outward of the foot. The fourth graphic (D) shows inversion, which is the turning inward of the foot.

A client reports abdominal pain. During her focused assessment, which action would the nurse implement to aid in her investigation of this complaint? Palpating the painful area last Checking for warmth in the painful area Using deep palpation Palpating the painful area first

Palpating the painful area last

A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. Which task should she assign to another LPN? Performing dressing changes Assisting clients with personal hygiene needs Assisting the clients with their meal trays Obtaining vital signs

Performing dressing changes

The nurse is examining a client with suspected peritonitis. What nursing intervention does the nurse use to elicit rebound tenderness? Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release Use deep ballottement, noting any tenderness over an area Use light palpation, noting any tenderness over an area Press firmly with one hand, release pressure while maintaining fingertip contact with the skin, and note tenderness on release

Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release

A client undergoes a total abdominal hysterectomy. When checking the client 10 hours later, the nurse identifies which finding as an early sign of shock? Urine output of 30 ml/hour Pale, warm, dry skin Heart rate of 110 beats/minute Restlessness

Restlessness

A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake? Explaining the need for increased fluid Serving fluids at appropriate temperatures Serving fluids in large amounts Placing the client's choices of beverages at the bedside

Serving fluids in large amounts

A nurse is caring for a client with myasthenia gravis. Which behavior during dinner indicates to the nurse that the client is having a therapeutic response to pyridostigmine? The client participates in conversation. The client swallows food without difficulty. The client begins to speak clearly. The client talks optimistically about the future.

The client swallows food without difficulty.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. On a return visit to the health care provider, the nurse observes the gait. Which observation indicates the need to reinforce client education about walker use? The client backs up to the chair until his legs touch the chair, and then sits down. The client moves his hands to the chair armrests before lowering himself into the chair. The client moves his weak leg forward with the walker. The client's arms are fully extended when using the walker.

The client's arms are fully extended when using the walker.

The nurse has just received the shift report. Which client should the nurse assess first? a 35-year-old client who had an abdominal hysterectomy 2 days ago and has stable vital signs a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84% a 76-year-old client admitted with chest pain whose last blood pressure was 136/92 mm Hg an 88-year-old client admitted with mental status changes whose vital signs are stable

a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84%

A client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply. cardiac tamponade pneumonia epiglottitis acute respiratory distress syndrome pulmonary edema

acute respiratory distress syndrome pneumonia pulmonary edema

The nurse is caring for a client who is concerned about skin cancer. Abnormal characteristics of pigmented skin lesions are defined by the mnemonic ABCDE. What does the mnemonic mean? asymmetry, black/brown, consistency, diameter, erythema asymmetry, border, color, diameter, elevation/enlargement asymmetry, black/brown, consistency, diameter, erythema ashen, border, color, diameter, elevation/enlargement

asymmetry, border, color, diameter, elevation/enlargement

The client presents to the clinic with reports of abdominal pain. When, during assessment, is the best time for the nurse to check this client for rebound tenderness? anytime during the examination before doing anything else at the end of the examination near the beginning of the examination

at the end of the examination

What finding would the nurse expect to see in a client admitted for possible Cushing's syndrome? weight gain in the upper and lower extremities hypotension, tachycardia, and tachypnea buildup of adipose tissue in the face and trunk thick, coarse skin with thinning hair and nails

buildup of adipose tissue in the face and trunk

While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate: presence of a foreign body. infection. cerebrospinal fluid leak. epistaxis.

cerebrospinal fluid leak.

The nurse is obtaining the health history of a client whose background differs from the nurse's. Which client factor should the nurse recognize to best develop culturally acceptable strategies for nursing care? marital status financial resources cultural influences community involvement

cultural influences

A client is prescribed misoprostol for treatment of a gastric ulcer. The nurse should be alert for which common adverse reaction related to dosage? nausea diarrhea vomiting bloating

diarrhea

A nurse is collecting data on an older adult client. Which finding should the nurse anticipate as part of the normal degenerative changes associated with aging? cloudy vision fine tremors incontinence diminished reflexes

diminished reflexes

A client reports slipping on a throw rug while going to the bathroom at night. Which data should be gathered for prevention of further falls? client confusion client has a urinary tract infection (UTI) home safety injury to the client's head

home safety

The nurse is palpating the client's arterial pulses. Which graphic displays the appropriate site for palpating the dorsalis pedis pulse?

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A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client? insomnia, cough with hemoptysis, and fatigue headache, fever, and diaphoresis hypotension, rapid pulse, and shortness of breath vertigo, weakness, and pulse changes

hypotension, rapid pulse, and shortness of breath

Which sequence should the nurse follow when collecting data for an abdominal examination? inspection of the outer appearance, auscultation of bowel and arterial sounds, percussion, and palpation of the tissue and underlying structures inspection of the outer appearance, percussion and palpation of the tissue and underlying structures, and auscultation of bowel and arterial sounds inspection of the outer appearance, auscultation of bowel and arterial sounds, and palpation and percussion of the tissue and underlying structures inspection, palpation, percussion, and auscultation

inspection of the outer appearance, auscultation of bowel and arterial sounds, percussion, and palpation of the tissue and underlying structures

A primipara client at 32 weeks' gestation comes to the hospital reporting vaginal bleeding. She has soaked one peri-pad and has no pain or cramps. Based on this data, the nurse would most likely suspect which condition? vasa previa abruptio placentae incompetent cervix placenta previa

placenta previa

The nurse is obtaining vital signs for several clients. Which client's vital signs would be the priority to report to the health care provider? healthy female client undergoing elective surgery with a blood pressure of 110/68 mm Hg client with a pulse of 120 beats/minute after 30 minutes of aerobic exercise in physical therapy postoperative client with a pulse of 110 beats/minute on awakening in the morning healthy male client who is undergoing elective surgery with a blood pressure of 120/72 mm Hg

postoperative client with a pulse of 110 beats/minute on awakening in the morning

A nurse is gathering data on a client diagnosed with appendicitis. Which signs and symptoms would the nurse expect to find? periumbilical pain, Trousseau sign, and pain relief with pressure rigid abdomen, Levine sign, and pain relief when leaning forward right lower quadrant pain, Chvostek sign, and muscle guarding rebound tenderness, McBurney sign, and low-grade fever

rebound tenderness, McBurney sign, and low-grade fever

When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education? reduced intelligence increased vein elasticity slowed reaction time electrolyte imbalances

slowed reaction time

A school nurse is obtaining data from a student at an elementary school. Which finding would lead the nurse to suspect impetigo? a discrete, pink-red, maculopapular rash that starts on the head and progresses down the body red spots with a blue base found on the buccal membranes vesicular lesions that ooze, forming crusts on the face and extremities small, red lesions on the trunk and in the skinfolds

vesicular lesions that ooze, forming crusts on the face and extremities

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? "The pulse can't be checked accurately if the arteries are palpated at the same time." "Checking both carotid arteries at the same time may impair cerebral circulation." "Checking both carotid arteries at the same time may cause severe tachycardia." "Checking both carotid arteries at the same time may cause transient hypertension."

"Checking both carotid arteries at the same time may impair cerebral circulation."

The nurse educator is explaining to a group of newly hired nurses how to auscultate a client's chest. What information would the nurse educator include to explain how to differentiate a pleural friction rub from other abnormal breath sounds? A rub occurs during inspiration only and clears with coughing. A rub occurs during expiration only and produces a light, popping, musical noise. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. A rub occurs during inspiration only and may be heard anywhere.

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

A nurse must evaluate a client's splinted extremity for neurovascular damage. What is the priority action by the nurse? Evaluate all extremities, ensuring that the extremity with the splint feels cooler. Be aware that edema and pulse checks are not part of a neurovascular evaluation. Compare color and capillary refill of both extremities. Manually move the client's fingers and toes to test movement.

Compare color and capillary refill of both extremities.

A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take? Instruct the client to call the home health agency when he arrives home. Notify the pharmacy of the client's medications. Notify the social worker of the discharge plans. Contact the home health agency and provide a report of the client's condition and needs.

Contact the home health agency and provide a report of the client's condition and needs.