NCLEX_practice_questions_Interventions_Nursing_PrepU

NCLEX_practice_questions_Interventions_Nursing_PrepU




Question 1: When performing an abdominal assessment, the nurse uses a
(see full question) different order of techniques than with other systems. Which of the
following represents this order


You selected: Inspection, auscultation, percussion, palpation


Correct


Explanation: In an abdominal assessment, start with inspection, then
auscultation, percussion, and palpation. This is the preferred
approach because palpation and percussion before auscultation
may alter the sounds heard. (less)




Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter
25: Health Assessment, p. 658.


Chapter 25: Health Assessment - Page 658




Question 2: The nurse in post-anesthesia recovery (PAR) is caring for a 27-
(see full question) year-old client following an appendectomy. Twenty minutes after
receiving 4 mg of intravenous (IV) morphine for abdominal pain, the
client continues to report abdominal discomfort and requests more
morphine. Which action by the nurse is best?


You selected: Observe the abdomen for distention and rigidity.


Correct


Explanation: Continued abdominal pain after administration of IV morphine is an
unexpected occurrence and requires further assessment by the
nurse to rule out peritonitis or internal bleeding by observing the
abdomen for distention and rigidity. Administration of more
morphine could mask the cause of the abdominal pain and delay
diagnosis of a possible postoperative complication. Applying heat to
the abdomen would increase blood flow to the area and potentially


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increase pain or internal bleeding. Positioning the client in a knees-
flexed position may relieve the discomfort, but an assessment is
needed before any intervention is implemented. (less)




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Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter
25: Health Assessment, p. 658.


Chapter 25: Health Assessment - Page 658




Question 3: The nurse will obtain the greatest amount of information about the
(see full question) thyroid gland by using which technique of assessment?


You selected: Palpation


Correct


Explanation: The thyroid gland is assessed by palpation, although it is not
normally palpable in some patients.


Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter
25: Health Assessment, pp. 647-648.


Chapter 25: Health Assessment - Page 647




Question 4: The nurse is asking admission interview questions and the client
(see full question) has explained the reason for seeking care. Which of the following is
the most appropriate way to document the response?


You selected: Client describes shortness of breath and increased sputum
production.


Incorrect




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Correct response: Client states, "I feel winded all of the time and yesterday I started
spitting up a lot of phlegm."




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