Practice for Unit 1 Exam- Fundamentals of Nursing

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen. B. Prior to percussing the abdomen C. After assessing for kidney tenderness. D. Prior to inspecting the abdomen.

Correct answer: B. Prior to percussing the abdomen According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply). 1- More difficulty seeing due to a greater sensitivity to glare 2- Decreased cough reflex 3- Decreased bladder capacity 4- Decreased systolic blood pressure 5- Dehydration of intervertebral discs

Correct answer: 1, 2, 3, & 5 -More difficulty seeing due to a greater sensitivity to glare is correct. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception. -Decreased cough reflex is correct. Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections. -Decreased bladder capacity is correct. Older adults have a decreased bladder capacity and a reduction in renal blood flow. -Decreased systolic blood pressure is incorrect. Older adults have increased systolic blood pressure, thickening of blood-vessel walls, and decreased peripheral circulation. -Dehydration of intervertebral discs is correct. Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.

Correct answer: A. Assess the apical pulse for a full minute. For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart.

An assistive personnel (AP) reports a client's vitals signs as tympanic temperature 37.1 C (98.8 F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? A. BP B. Respiratory rate C. Pulse rate D. Temperature

Correct answer: A. BP A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include? A. Decreased muscle mass. B. Thickened vertebral disks C. Reduced chest width D. Increased force of isometric contraction.

Correct answer: A. Decreased muscle mass. A decrease in muscle mass and strength occurs with aging.

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? A. Elicit information from the client. B. Encourage the client to use self-exploration. C. Review the client's progress toward the personal objectives. D. Talk with others who have information about the client.

Correct answer: A. Elicit information from the client. Obtaining information from the client is a component of the orientation phase.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? A. Temporary urinary retention B. Urinary frequency for several days. C. Blood-tinged urine D. Highly concentrated urine.

Correct answer: A. Temporary urinary retention Until the bladder regains its full tone, it is common for clients to develop urinary retention. If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A nurse is assessing a client for putting edema and notes an indentation of 6mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? A. 4+ B. 3+ C. 2+ D. 1+

Correct answer: B. 3+ The nurse should document pitting edema of 5 to 7 mm as 3+.

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? A. Glasgow results B. Intracranial pressure readings C. Code status. D. Plan of care changes for upcoming shift.

Correct answer: C. Code status The nurse should report the client's current code stats in the background segment of SBAR.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

The posterior tibial pulse is located on the inner ankle, one-third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? A. Client concerns B. Family information. C. Medical history D. Progress note

CORRECT ANSWER: A. Client concerns. Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

A nurse is having a difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take? A. Clarify the type of medication with the family. B. Review the medication history on the admission record. C. Send the prescription to the pharmacist to clarify. D. Contact the provider to clarify the prescription.

Correct answer: D. Contact the provider to clarify the prescription. To prevent a medication error, the nurse should clarify the unclear prescription with the provider.

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document which of the following adventitious breath sounds? A. Crackles B. Rhonchi C. Stridor D. Wheezes

Correct answer: D. Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct answer: C. Nausea Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? A. Teach the client about his diagnosis. B. Provide a schedule of visiting hours to the client's family. C. Document the client's allergies in the electronic medical record. D. Develop a plan of care for the client.

Correct answer: C. Document the client's allergies in the electronic medical record. The greatest risk to this client is injury from incomplete or inaccurate documentation. Therefore, the first action the nurse should take is to document the assessment findings in the client's medical record. This will allow for continuity of care and reduces the risk for injury due to inaccurate documentation.

A nurse is working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening? A. Infant B. Toddler/Preschooler C. Pre-adolescent/adolescent D. Older adult

Correct answer: C. Pre-adolescent/adolescent Scoliosis is a condition involving a lateral curvature to the spine. The nurse should include screening for scoliosis during the pre-adolescence/adolescence age group: for girls in grades 5 through 7 and for boys in grade 8 or 9.

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate

Correct Answer: C. Inspect Evidence-based practice indicates the nurse should first inspect the abdomen for external abnormal conditions first.

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply). -Repeat the order back to the provider -Question any part of the order that is unclear or inappropriate. -Transcribe the order into the client's health record -Obtain the provider's signature within 8 hr. -Implement a recorded order message if the nurse can hear and understand it clearly.

Correct answer: -Repeat the order back to the provider is correct. The nurse should read the order back and have the provider verbally confirm that it is correct. -Question any part of the order that is unclear or inappropriate is correct. The nurse should question any part of the prescription or an order that is unclear or inappropriate. This is essential for any verbal or written prescription or order. -Transcribe the order into the client's health record is correct. The prescription should be entered in the health record as it is obtained and verified. -Obtain the provider's signature within 8 hr is incorrect. Although the policy may vary with each facility, the usual rule is to obtain the provider's signature within 24 hr. -Implement a recorded order message if the nurse can hear and understand it clearly is incorrect. If a provider leaves a recorded order message, the nurse should call the provider and obtain the prescription verbally over the telephone.

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify an an interpersonal variable? (Select all that apply). 1- Education 2- Feedback 3- Gender 4- Perception 5- Time

Correct answer: 1, 3, & 4 -Education is correct. The educational background of the client is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships. -Feedback is incorrect. Feedback is the message that the sender returns in the communication process. It is not an interpersonal variable. -Gender is correct. Gender is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships. -Perception is correct. Perception provides a uniquely personal view to a client's experience and is an interpersonal variable that affects communication. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships. -Time is incorrect. Time is a critical element of the communication process, but it is not an interpersonal variable.

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps that the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all of the steps) 1-Auscultate the abdomen for bowel sounds. 2- Inspect the abdomen for skin integrity 3- Palpate the abdomen lightly for tenderness 4- Ask the client about having a history of abdominal pain. 5- Percuss the abdomen in each of the four quadrants.

Correct answer: 4, 2, 1, 5, & 3 Before initiating an abdominal assessment, the nurse should inquire if the client has a history of abdominal pain. The nurse should begin the assessment with an inspection of the client's abdomen, noting skin integrity, contour, and symmetry. Next, the nurse should auscultate for bowel sounds, vascular sounds, and peritoneal friction rubs. Auscultation precedes palpation and percussion because movement or stimulation of the bowel can increase bowel motility and create false results from heightened bowel sounds. After auscultation, the nurse should percuss the abdomen using a systematic pattern beginning in the lower right quadrant and proceeding to the upper right quadrant, the upper left quadrant, and then the lower left quadrant to determine the presence of tympany and dullness. The final step the nurse should take is to palpate the abdomen, beginning with light palpation, to detect any area of tenderness or muscle guarding.

A nurse is orienting a newly licensed nurse about documentation of a client's information tin the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A. "Documentation is a communication tool for the inter professional health care team." B. "Documentation provides information to the client about financial charges for care provided." C. "Documentation provides information for a client audit." D. "Documentation allows providers to monitor the nurse's activities."

Correct answer: A. "Documentation is a communication tool for the inter professional health care team." Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies and evaluating a client's progress.

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? A. Wraps the blood pressure cuff snugly around the client B. Places the client's arm above the level of the client's heart C. Checks the instrument gauge to ensure the reading starts at zero. D. Centers the cuff bladder over the client's brachial artery.

Correct answer: B. Places the client's arm above the level of the client's heart The partner should place the client's arm at heart level to ensure accurate blood pressure readings.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot.

Correct answer: C. Conjunctivae To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet (plantar surface), conjunctivae, and mucous membranes.

A nurse caring for a client is using active listening skills. Which of the actions should the nurse take? A. Sit side-by-side with the client. B. Have a pen and paper handy. C. Use intermittent eye contact. D. Lean back in the chair.

Correct answer: C. Use intermittent eye contact. The nurse should establish intermittent eye contact and maintain it during active listening. It demonstrates interest is what the client is saying.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing th client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. "There were no injuries sustained." B. "An incident report was completed." C. "An incident report was forwarded to risk management." D. "The provider was notified."

Correct answer: D. "The provider was notified." Nursing interventions that support factual information should be documented in the health record.

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? A. Clamps the NG tube during auscultation B. Performs auscultation between meals C. Auscultates bowel sounds for 3 to 5 min D. Palpates the abdomen prior to performing auscultation.

Correct answer: D. Palpates the abdomen prior to performing auscultation. The nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? A. Focus on the client's present circumstances instead of his personal stories. B. Verbalize understanding of how the client feels. C. Offer the client personal thoughts and beliefs. D. Use attentive listening with the client

Correct answer: D. Use attentive listening with the client When establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding.

A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors? A. When determining if the client is eating a well-balanced diet. B. When asking the client about his receptiveness to the transfer. C. When asking the client how he completes his ADLs. D. When asking if the client took his medications this morning

Correct answer: D. When asking if the client took his medications this morning A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further.

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

Correct answer: The nurse should auscultate the client's apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6 cm (about 3 in) to the left of the sternum.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? A. Logging out of the computer before leaving a terminal. B. Sharing computer passwords with coworkers C. Using a computer terminal in a non-public area. D. Preventing an unidentified health care worker from viewing a health record on the computer screen.

Correct answer: B. Sharing computer passwords with coworkers This action violates client confidentiality by allowing coworkers to access information which they may not be authorized to view.