Jensen chapter 29 Exam Questions and Answers Already Passed Latest Update 2025-2026
When performing a shift assessment, the nurse identifies the client has on a sequential
compression device. What must the nurse then assess?
-Skin
-Breath sounds
-Temperature
-Blood sugar - Answers skin
The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which
urinary output value indicates acute oliguria?
-80 mL in past 2 hours
-100 mL in past 2 hours
-120 mL in past 2 hours
-50 mL in past 2 hours - Answers 50 mL in past 2 hours
During the admission assessment, the nurse identifies the client has a history of Raynaud's.
What assessment finding would the nurse expect to find?
-Cool legs bilaterally
-Cool leg on one side
-Cold fingers and hands
-Capillary refill less than 2 seconds - Answers cold fingers and hands
When you enter the room of a hospitalized patient, you note that the patient is guarding her left
leg, which is swollen and reddened. You should identify the signs and symptoms of what
complication of hospitalization?
-Decreased mobility
-Sepsis
-Venous thromboembolism
-Fluid imbalance - Answers venous thromboembolism
A client is admitted for observation after complaining of chest pain. A 12-lead
electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge
,about whether the client can be observed or should be sent home because the ECG is normal.
What is the charge nurse's best response?
-"Call the healthcare provider to change the admitting diagnosis."
-"Tell the client that insurance will not pay for observation."
-"It's acceptable for a client to admitted for observation."
-"Refuse to admit the client without a proper medical diagnosis." - Answers its acceptable for a
client to admitted for observation
Which Glasgow Coma Score indicates the client is in a deep coma?
-3
-8
-14
-15 - Answers 3
What abnormal physical response should the nurse be prepared to manage after noting pallor in
a client?
-fainting
-vomiting
-diarrhea
-diaphoresis - Answers fainting
The nurse is performing a shift assessment on a client who just received a central line. Which
finding should the nurse report as a complication of central line placement?
-Respiratory rate of 20 breaths per minute
-Temperature of 97.6 degrees Fahrenheit
-Elevated blood pressure while lying in bed
-Decreased breath sounds unilaterally - Answers decreased breath sounds unilaterally
Which of the following changes in a hospitalized patient's status should prompt you to perform
an urgent assessment?
-Increase in heart rate from 80 beats per minute (BPM) to 110 BPM
,-Expressed dissatisfaction with the quality of care
-A new onset of confusion
-A newly developed rash accompanied by pruritus - Answers a new onset of confusion
When assessing for apocrine gland function, the nurse would assess for moisture where on the
client's body?
-palms of the hands
-face
-soles of the feet
-underarms - Answers underarms
The nurse assesses the client's pulses to be normal. These would be documented how?
-O
-1+
-2+
-3+ - Answers 2+
A client presents to the emergency department complaining of new onset chest pain. What is
the priority action of the nurse?
-Collect client's health history.
-Reconcile current medications.
-Place on cardiac monitor.
-Record the client's allergies. - Answers place on cardiac monitor
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
-Client stands erect with minimal swaying
-Client sways when eyes are closed
-Client prevents himself from falling
-Client maintains balance when walking - Answers client stands erect with minimal swaying
A mental status examination consists of various components. Which assessment data is
associated with cognitive function? Select all that apply.
, -Client is dressed appropriately for the weather.
-Client is able to successfully multiple 24 times 32.
-Client correctly names the last three presidents of the United States.
-Client's verbal skills are appropriate for age.
-Client reports frequently seeing a dead parent. - Answers -Client is able to successfully multiple
24 times 32.
-Client correctly names the last three presidents of the United States.
Which of the following would put the client at risk for falls? Select all that apply.
-Confusion
-Palpitations
-Diaphoresis
-Dizziness
-Hypotension - Answers -hypotension
-confusion
-dizziness
The nurse is caring for a client hospitalized for surgical repair of a foot fracture. How should the
nurse assess the muscle strength in the client's feet?
-Ask client to rotate the ankles in a clockwise fashion.
-Palpate the dorsalis pedis areas in each foot.
-Tell client to push feet against resistance.
-Check for edema on plantar and dorsal surfaces. - Answers tell client to push feet against
resistance
The nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery.
Place the following assessment steps in order as the nurse enters the client's room.
Auscultate all four quadrants.
Palpate for tenderness.
Perform a general survey of safety hazards.
When performing a shift assessment, the nurse identifies the client has on a sequential
compression device. What must the nurse then assess?
-Skin
-Breath sounds
-Temperature
-Blood sugar - Answers skin
The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which
urinary output value indicates acute oliguria?
-80 mL in past 2 hours
-100 mL in past 2 hours
-120 mL in past 2 hours
-50 mL in past 2 hours - Answers 50 mL in past 2 hours
During the admission assessment, the nurse identifies the client has a history of Raynaud's.
What assessment finding would the nurse expect to find?
-Cool legs bilaterally
-Cool leg on one side
-Cold fingers and hands
-Capillary refill less than 2 seconds - Answers cold fingers and hands
When you enter the room of a hospitalized patient, you note that the patient is guarding her left
leg, which is swollen and reddened. You should identify the signs and symptoms of what
complication of hospitalization?
-Decreased mobility
-Sepsis
-Venous thromboembolism
-Fluid imbalance - Answers venous thromboembolism
A client is admitted for observation after complaining of chest pain. A 12-lead
electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge
,about whether the client can be observed or should be sent home because the ECG is normal.
What is the charge nurse's best response?
-"Call the healthcare provider to change the admitting diagnosis."
-"Tell the client that insurance will not pay for observation."
-"It's acceptable for a client to admitted for observation."
-"Refuse to admit the client without a proper medical diagnosis." - Answers its acceptable for a
client to admitted for observation
Which Glasgow Coma Score indicates the client is in a deep coma?
-3
-8
-14
-15 - Answers 3
What abnormal physical response should the nurse be prepared to manage after noting pallor in
a client?
-fainting
-vomiting
-diarrhea
-diaphoresis - Answers fainting
The nurse is performing a shift assessment on a client who just received a central line. Which
finding should the nurse report as a complication of central line placement?
-Respiratory rate of 20 breaths per minute
-Temperature of 97.6 degrees Fahrenheit
-Elevated blood pressure while lying in bed
-Decreased breath sounds unilaterally - Answers decreased breath sounds unilaterally
Which of the following changes in a hospitalized patient's status should prompt you to perform
an urgent assessment?
-Increase in heart rate from 80 beats per minute (BPM) to 110 BPM
,-Expressed dissatisfaction with the quality of care
-A new onset of confusion
-A newly developed rash accompanied by pruritus - Answers a new onset of confusion
When assessing for apocrine gland function, the nurse would assess for moisture where on the
client's body?
-palms of the hands
-face
-soles of the feet
-underarms - Answers underarms
The nurse assesses the client's pulses to be normal. These would be documented how?
-O
-1+
-2+
-3+ - Answers 2+
A client presents to the emergency department complaining of new onset chest pain. What is
the priority action of the nurse?
-Collect client's health history.
-Reconcile current medications.
-Place on cardiac monitor.
-Record the client's allergies. - Answers place on cardiac monitor
The nurse is performing the Romberg test. Which of the following indicate a normal finding?
-Client stands erect with minimal swaying
-Client sways when eyes are closed
-Client prevents himself from falling
-Client maintains balance when walking - Answers client stands erect with minimal swaying
A mental status examination consists of various components. Which assessment data is
associated with cognitive function? Select all that apply.
, -Client is dressed appropriately for the weather.
-Client is able to successfully multiple 24 times 32.
-Client correctly names the last three presidents of the United States.
-Client's verbal skills are appropriate for age.
-Client reports frequently seeing a dead parent. - Answers -Client is able to successfully multiple
24 times 32.
-Client correctly names the last three presidents of the United States.
Which of the following would put the client at risk for falls? Select all that apply.
-Confusion
-Palpitations
-Diaphoresis
-Dizziness
-Hypotension - Answers -hypotension
-confusion
-dizziness
The nurse is caring for a client hospitalized for surgical repair of a foot fracture. How should the
nurse assess the muscle strength in the client's feet?
-Ask client to rotate the ankles in a clockwise fashion.
-Palpate the dorsalis pedis areas in each foot.
-Tell client to push feet against resistance.
-Check for edema on plantar and dorsal surfaces. - Answers tell client to push feet against
resistance
The nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery.
Place the following assessment steps in order as the nurse enters the client's room.
Auscultate all four quadrants.
Palpate for tenderness.
Perform a general survey of safety hazards.
