Exam (elaborations) NURS 4414 (NURS 4414Basic Physical Assessment) (NURS 4414 - Basic Physical Assessment.)

Question 1 See full question 36s Report this Question A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? You Selected: • "What does the pain feel like?" Correct response: • "What does the pain feel like?" Explanation: Remediation: Add a Note Question 2 See full question 50s Report this Question Which component of a client's medical record is the major source of subjective data about the client's health status? You Selected: • health history Correct response: • health history Explanation: Remediation: Add a Note Question 3 See full question 7s Report this Question To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site? You Selected: • carotid Correct response: • carotid Explanation: Remediation: Add a Note Question 4 See full question 40s Report this Question Which plane divides the body longitudinally into anterior and posterior regions? You Selected: • sagittal plane Correct response: • frontal plane Explanation: Add a Note Question 5 See full question 43s Report this Question A nurse correctly identifies which items as belonging to the dorsal cavity? You Selected: • vertebral canal Correct response: • vertebral canal Explanation: Add a Note Question 6 See full question 1m 12s Report this Question A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client? You Selected: • normal skin turgor is moist and boggy Correct response: • inelastic skin turgor is a normal part of aging Explanation: Remediation: Add a Note Question 7 See full question 16s Report this Question A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain? You Selected: • frontal Correct response: • temporal Explanation: Remediation: Add a Note Question 8 See full question 2m 52s Report this Question A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client? You Selected: • Take her temperature at the same time every morning before getting out of bed. Correct response: • Take her temperature at the same time every morning before getting out of bed. Explanation: Add a Note Question 9 See full question 11s Report this Question Which findings should the nurse expect to assess as normal skin changes in an older adult? Select all that apply. You Selected: • solar lentigo • wrinkles • diminished hair on scalp and pubic areas Correct response: • diminished hair on scalp and pubic areas • solar lentigo • wrinkles • xerosis Explanation: Remediation: Add a Note Question 10 See full question 55s Report this Question The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client’s respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client’s level of consciousness is declining. What should the nurse do first? You Selected: • Call the rapid response team (RRT)/medical emergency team. Correct response: • Call the rapid response team (RRT)/medical emergency team. Explanation: Remediation: Add a Note Question 11 See full question 26s Report this Question The nurse is caring for a client who has just had an upper GI endoscopy. The client’s vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next? You Selected: • Promptly assess the client for potential perforation. Correct response: • Promptly assess the client for potential perforation. Explanation: Add a Note Question 12 See full question 1m 13s Report this Question Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client’s postprocedure status. Which outcome is expected? You Selected: • There is no bleeding at the aspiration site. Correct response: • There is no bleeding at the aspiration site. Explanation: Remediation: Add a Note Question 13 See full question 16s Report this Question A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? You Selected: • fat embolus Correct response: • thrombophlebitis Explanation: Remediation: Add a Note Question 14 See full question 13m 38s Report this Question The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. What should the nurse do next? You Selected: • Begin chest compressions. Correct response: • Call the rapid response team. Explanation: Remediation: Add a Note Question 15 See full question 14s Report this Question A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? You Selected: • Assess the client's level of pain, and administer prescribed analgesics. Correct response: • Assess the client's level of pain, and administer prescribed analgesics. Explanation: Remediation: Add a Note Question 16 See full question 21s Report this Question A client with a spinal cord injury says they are having difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury? You Selected: • burning sensation on urination Correct response: • fever and change in urine clarity Explanation: Remediation: Add a Note Question 17 See full question 14s Report this Question The nurse is observing a nursing student palpating a client’s maxillary sinuses. The nurse observes that the student has correctly palpated the client’s maxillary sinuses when the student palpates which area? You Selected: • below the client's cheekbones Correct response: • below the client's cheekbones Explanation: Remediation: Add a Note Question 18 See full question 18s Report this Question The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170 cm) female client who is 21 years of age? You Selected: • brittle nails Correct response: • brittle nails Explanation: Remediation: Add a Note Question 19 See full question 23s Report this Question A graduate nurse is assessing a client with Meniere's Disease and a positive Romberg's sign. What is the nurse's highest priority when delivering care? You Selected: • Place client on fall precautions. Correct response: • Place client on fall precautions. Explanation: Remediation: Add a Note Question 20 See full question 9s Report this Question Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube? You Selected: • Auscultation indicates bowel sounds in all four quadrants. Correct response: • Auscultation indicates bowel sounds in all four quadrants. Explanation: Remediation: Add a Note Question 21 See full question 2m 16s Report this Question Which of the following statements heard during shift report identifies an important priority for action? You Selected: • A postoperative client’s pulse has been increasing, and the blood pressure is decreasing. Correct response: • A postoperative client’s pulse has been increasing, and the blood pressure is decreasing. Explanation: Add a Note Question 22 See full question 15s Report this Question When teaching a group of middle-aged women, what would the nurse include when discussing primary prevention? You Selected: • prevention of osteoporosis, the importance of regular breast self-examinations, and Pap smears Correct response: • prevention of osteoporosis, the importance of regular breast self-examinations, and Pap smears Explanation: Remediation: Add a Note Question 23 See full question 33s Report this Question A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? You Selected: • signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes Correct response: • signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes Explanation: Remediation: Add a Note Question 24 See full question 11s Report this Question A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? You Selected: • Level of consciousness, pain level, and wound dressing Correct response: • Level of consciousness, pain level, and wound dressing Explanation: Remediation: Add a Note Question 25 See full question 30s Report this Question Students in a health class are discussing birth control and prevention of sexually transmitted disease. The school nurse would know that teaching has been effective if the students state which of the following? You Selected: • “Safe sex means preventing pregnancy through use of birth control.” Correct response: • “Responsible sex involves using condoms and spermicides for protection and birth control.” Explanation: Remediation: Add a Note Question 26 See full question 21s Report this Question Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which of the following would be the best response by the nurse? You Selected: • “A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.” Correct response: • “A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.” Explanation: Remediation: Add a Note Question 27 See full question 26s Report this Question After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention? You Selected: • Perform a bladder scan, and obtain an order for urinary catheterization. Correct response: • Perform a bladder scan, and obtain an order for urinary catheterization. Explanation: Remediation: Add a Note Question 28 See full question 9s Report this Question The nurse is assessing a client’s respiratory status. Which assessment data indicate a problem? You Selected: • 28 breaths/min and audible Correct response: • 28 breaths/min and audible Explanation: Remediation: Add a Note Question 29 See full question 13s Report this Question A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained? You Selected: • development of an increase in mobility Correct response: • development of an increase in mobility Explanation: Remediation: Add a Note Question 30 See full question 45s Report this Question A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates what regarding a client’s clinical status? You Selected: • changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person Correct response: • changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person Explanation: Remediation: Add a Note Question 31 See full question 23s Report this Question A client’s arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation? You Selected: • metabolic acidosis Correct response: • metabolic acidosis Explanation: Remediation: Add a Note Question 32 See full question 16s Report this Question A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding? You Selected: • pulse amplitude +1 bilateral lower extremities Correct response: • pulse amplitude +1 bilateral lower extremities Explanation: Remediation: Add a Note Question 33 See full question 22s Report this Question The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse’s initial actions? You Selected: • Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. Correct response: • Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. Explanation: Remediation: Add a Note Question 34 See full question 9m 38s Report this Question A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). What should the nurse do next? You Selected: • Encourage the client to increase fluid intake. Correct response: • Encourage the client to increase fluid intake. Explanation: Remediation: Add a Note Question 35 See full question 20s Report this Question The nurse is assessing the client's umbilicus (see the accompanying image). The nurse should document the umbilicus as being: You Selected: • midline. Correct response: • midline. Explanation: Add a Note Question 36 See full question 3m 55s Report this Question Which finding will the nurse assess in a client diagnosed with peritonitis? You Selected: • abdominal wall rigidity Correct response: • abdominal wall rigidity Explanation: Remediation: Add a Note Question 37 See full question 24s Report this Question The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? You Selected: • Palpate for the bladder above the symphysis pubis. Correct response: • Palpate for the bladder above the symphysis pubis. Explanation: Remediation: Add a Note Question 38 See full question 15s Report this Question Which finding in a client who recently underwent a total hip replacement would require a nurse to take immediate action? You Selected: • red painful area on the calf of the affected leg Correct response: • red painful area on the calf of the affected leg Explanation: Remediation: Add a Note Question 39 See full question 23s Report this Question The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note? You Selected: • C Correct response: • C Explanation: Add a Note Question 40 See full question 31s Report this Question The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client’s safety. The nurse should include which targeted assessments? Select all that apply. You Selected: • suicide or self-harm ideation • recent use of substances of abuse • allergic reactions or adverse drug reactions Correct response: • suicide or self-harm ideation • recent use of substances of abuse • allergic reactions or adverse drug reactions Explanation: Add a Note Question 41 See full question 1m 3s Report this Question The most appropriate way for the nurse to assess a client’s ability to perform activities of daily living is to: You Selected: • observe client performing varied activities of daily living. Correct response: • observe client performing varied activities of daily living. Explanation: Add a Note Question 42 See full question 1m 49s Report this Question A nurse is completing a health assessment with an adult client in a healthcare provider’s office. What assessment data will the nurse report to the healthcare provider as indications of fluid volume excess? Select all that apply. You Selected: • decreased heart rate • pitting extremity edema • bounding pulses Correct response: • bounding pulses • pitting extremity edema • feelings of fatigue Explanation: Remediation: Add a Note Question 43 See full question 35s Report this Question When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply. You Selected: • allergies to any medications • allergies to items other than medications, such as foods and animals • reaction to the allergen • severity of the allergy Correct response: • allergies to any medications • allergies to items other than medications, such as foods and animals • reaction to the allergen • severity of the allergy Explanation: Remediation: Add a Note Question 44 See full question 2m Report this Question The charge nurse on a pediatric unit is making clientnassignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? You Selected: • a 4-year-old with chronic graft-versus-host disease who is incontinent Correct response: • a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: Remediation: Add a Note Question 45 See full question 24s Report this Question The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first? You Selected: • a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output Correct response: • a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output Explanation: Remediation: Add a Note Question 46 See full question 22s Report this Question A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would be evaluated as correct? You Selected: • wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference Correct response: • wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference Explanation: Remediation: Add a Note Question 47 See full question 11s Report this Question A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make? You Selected: • level of consciousness, pain level, and wound dressing Correct response: • level of consciousness, pain level, and wound dressing Explanation: Remediation: Add a Note Question 48 See full question 9s Report this Question The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output? You Selected: • weighing the diaper before and after micturition Correct response: • weighing the diaper before and after micturition Explanation: Remediation: Add a Note Question 49 See full question 51s Report this Question A cloth chest restraint has been presecribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client? You Selected: • Check the extremities for circulation based on hospital protocols. Correct response: • Check the extremities for circulation based on hospital protocols. Explanation: Remediation: Add a Note Question 50 See full question 20s Report this Question The emergency department nurse is responsible for monitoring a 5-year-old client who is recovering from a moderate sedation procedure for reducing a forearm fracture. In the recovery phase, the child begins to wake up and is whimpering and crying, "Ouch, ouch, ouch." What should the nurse do? You Selected: • Assess pain using Wong-Baker FACES tool. Correct response: • Assess pain using Wong-Baker FACES tool. Question 1 See full question 41s Report this Question A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress? You Selected: • The client's pulse and respiratory rate returned to baseline 1 hour after activity. Correct response: • The client's pulse and respiratory rates increased moderately during ambulation. Explanation: Add a Note Question 2 See full question 58s Report this Question A client from Mexico has bacterial pneumonia and has a temperature of 102°F (39°C). The client has been treating the infection by drinking milk. How should the nurse interpret the client’s method of self-treatment? You Selected: • The client is using the hot disease concept. Correct response: • The client is using the hot disease concept. Explanation: Add a Note Question 3 See full question 1m 30s Report this Question A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? You Selected: • ineffective breathing pattern Correct response: • ineffective breathing pattern Explanation: Remediation: Add a Note Question 4 See full question 16s Report this Question While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis. You Selected: • Your selection and the correct area, market by the green box. Explanation: Remediation: Add a Note Question 5 See full question 9s Report this Question To evaluate a client's cerebellar function, a nurse should ask You Selected: • "Do you have any problems with balance?" Correct response: • "Do you have any problems with balance?" Explanation: Remediation: Add a Note Question 6 See full question 38s Report this Question A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma? You Selected: • "At first, the stoma may bleed slightly when touched." Correct response: • "At first, the stoma may bleed slightly when touched." Explanation: Remediation: Add a Note Question 7 See full question 52s Report this Question A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control? You Selected: • The client exhibits signs of adequate GI perfusion with normal bowel sounds. Correct response: • The client exhibits signs of adequate GI perfusion with normal bowel sounds. Explanation: Remediation: Add a Note Question 8 See full question 1m 11s Report this Question A client has had hoarseness for more than 2 weeks. What should the nurse do? You Selected: • Assess the client for dysphagia. Correct response: • Assess the client for dysphagia. Explanation: Remediation: Add a Note Question 9 See full question 28s Report this Question An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply. You Selected: • acute respiratory distress syndrome • pulmonary edema • pneumonia Correct response: • acute respiratory distress syndrome • pneumonia • pulmonary edema Explanation: Remediation: Add a Note Question 10 See full question 38s Report this Question A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? You Selected: • Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Correct response: • Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Explanation: Remediation: Add a Note Question 11 See full question 33s Report this Question In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? You Selected: • health habits, family relationships, affect, and thought patterns Correct response: • health habits, family relationships, affect, and thought patterns Explanation: Add a Note Question 12 See full question 14s Report this Question Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? You Selected: • urine output of 90 mL over the past 6 hours Correct response: • urine output of 90 mL over the past 6 hours Explanation: Remediation: Add a Note Question 13 See full question 2m 30s Report this Question A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate: You Selected: • respiratory acidosis. Correct response: • respiratory acidosis. Explanation: Remediation: Add a Note Question 14 See full question 3m 9s Report this Question The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition? You Selected: • allergies Correct response: • allergies Explanation: Remediation: Add a Note Question 15 See full question 11s Report this Question The nurse is assessing a client’s deep tendon reflexes. Which graphic shows assessing the biceps reflex? You Selected: • Correct response: • Explanation: Remediation: Add a Note Question 16 See full question 1m 11s Report this Question The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used. You Selected: • Hello. My name is Nurse Jones from Unit D. • I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. • Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. • Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. • I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Correct response: • Hello. My name is Nurse Jones from Unit D. • I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. • Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. • Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. • I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. Explanation: Add a Note Question 17 See full question 19s Report this Question The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply. You Selected: • a client with pain related to pancreatitis • a client who underwent cholecystectomy today • a client with intractable vomiting and diarrhea Correct response: • a client who underwent cholecystectomy today • a client with pain related to pancreatitis Explanation: Remediation: Add a Note Question 18 See full question 23s Report this Question The emergency department (ED) nurse should assess which client first? You Selected: • a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain Correct response: • a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain Explanation: Remediation: Add a Note Question 19 See full question 58s Report this Question The nurse is preparing the prescribed fentanyl 25 mcg I.V. After obtaining a fentanyl 50 mcg/ml vial, what is the priority action by the nurse? You Selected: • Draw 0.5 ml medication into a syringe, draw the remaining 0.5 ml into another syringe, and ask another nurse to witness the waste of 0.5 ml into the sink. Correct response: • Draw 0.5 ml medication into a syringe, draw the remaining 0.5 ml into another syringe, and ask another nurse to witness the waste of 0.5 ml into the sink. Explanation: Remediation: Add a Note Question 20 See full question 17s Report this Question The nurse is caring for a client that had surgery this morning. What assessment finding would the nurse notify the health care provider about? You Selected: • urinary output of 20 mL/hr over 2 hours Correct response: • urinary output of 20 mL/hr over 2 hours Explanation: Remediation: AVG./MEDIAN TIME ON QUESTION7m 9s/26s CORRECTLY ANSWERED15 of 20 questions • Take Another Quiz • See your Overall Performance • See your Quiz History Performance by nursing topic What's this? Basic Physical Assessment 3 quizzes taken Your mastery after this quiz 4 Class average 6.83 View current mastery performance for all nursing topics Answer Key Question 1 See full question 1m 21s Report this Question After administering prescribed medications to clients, which client requires immediateintervention? You Selected: • a client taking digoxin who has a morning potassium level of 3.0 mEq/L Correct response: • a client taking digoxin who has a morning potassium level of 3.0 mEq/L Explanation: Remediation: Add a Note Question 2 See full question 24m 27s Report this Question The nurse has received the change-of-shift report on the clients. Who should the nurse assess first? You Selected: • a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due Correct response: • a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due Explanation: Add a Note Question 3 See full question 38s Report this Question A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client’s rash? Select all that apply. You Selected: • "Have you recently traveled outside the country?" • "Are you allergic to any medications, foods, or pollen?" • "What have you been using to treat the rash?" • "When did the rash start?" Correct response: • "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 recently traveled outside the country?" Explanation: Remediation: Add a Note Question 4 See full question 25s Report this Question Which factors are major components of a client's general background history? You Selected: • allergies and socioeconomic status Correct response: • allergies and socioeconomic status Explanation: Remediation: Add a Note Question 5 See full question 10s Report this Question When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis? You Selected: • oral mucous membranes Correct response: • oral mucous membranes Explanation: Remediation: Add a Note Question 6 See full question 2m 15s Report this Question The nurse is assessing a client’s activity tolerance. Which report from a treadmill test indicates an abnormal response? You Selected: • respiratory rate decreased by 5 breaths/minute Correct response: • respiratory rate decreased by 5 breaths/minute Explanation: Add a Note Question 7 See full question 20s Report this Question For which client is the nursing assessment of pain most likely to result in undertreatment? You Selected: • an older adult who grimaces and states no pain after a gastrostomy tube placement Correct response: • an older adult who grimaces and states no pain after a gastrostomy tube placement Explanation: Remediation: Add a Note Question 8 See full question 15s Report this Question When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include You Selected: • delayed gastric emptying. Correct response: • delayed gastric emptying. Explanation: Add a Note Question 9 See full question 31s Report this Question A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate? You Selected: • cardiac monitoring, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels Correct response: • ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel Explanation: Remediation: Add a Note Question 10 See full question 13s Report this Question A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? You Selected: • teaching a client who has asthma how to use a rescue inhaler Correct response: • obtaining a rubella titer on a woman who is planning to start a family Explanation: Remediation: Add a Note Question 11 See full question 42s Report this Question The nurse is receiving over the telephone a laboratory results report of a neonate’s blood glucose level. What should the nurse do? You Selected: • Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Correct response: • Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. Explanation: Add a Note Question 12 See full question 1h 47m 45s Report this Question Which client should the nurse assess first? You Selected: • a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week Correct response: • a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: Add a Note Question 13 See full question 36s Report this Question The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury? You Selected: • The client’s vital signs will stabilize, returning to normal range. Correct response: • The client’s vital signs will stabilize, returning to normal range. Explanation: Add a Note Question 14 See full question 1m 8s Report this Question A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? You Selected: • Obtain vital signs. Correct response: • Obtain vital signs. Explanation: Remediation: Add a Note Question 15 See full question 17s Report this Question A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases? You Selected: • bradypnea Correct response: • tachypnea Explanation: Remediation: Add a Note Question 16 See full question 27s Report this Question The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative? You Selected: • “Just as I get over a virus, it seems that I get another.” Correct response: • “Just as I get over a virus, it seems that I get another.” Explanation: Add a Note Question 17 See full question 19s Report this Question A nurse can auscultate for heart sounds more easily if the client is You Selected: • on his right side. Correct response: • leaning forward. Explanation: Remediation: Add a Note Question 18 See full question 20s Report this Question The nurse notes serous discharge when an abdominal dressing is changed. The nurse would document this drainage as which of the following? You Selected: • clear, watery, yellow-tinged drainage Correct response: • clear, watery, yellow-tinged drainage Explanation: Add a Note Question 19 See full question 25s Report this Question Which of the following observations by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? You Selected: • formula in the client’s mouth during the feeding, and increased cough Correct response: • formula in the client’s mouth during the feeding, and increased cough Explanation: Remediation: Add a Note Question 20 See full question 12s Report this Question A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? You Selected: • vesicles Correct response: • vesicles Question 1 See full question 1m 24s Report this Question The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? You Selected: • high pitched gurgling noises in four abdominal quadrants Correct response: • high pitched gurgling noises in four abdominal quadrants Explanation: Remediation: Add a Note Question 2 See full question 3m 33s Report this Question At 8 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next? You Selected: • Immediately notify the healthcare provider of these findings. Correct response: • Immediately notify the healthcare provider of these findings. Explanation: Remediation: Add a Note Question 3 See full question 2m 45s Report this Question When examining a client who has abdominal pain, a nurse should assess You Selected: • the symptomatic quadrant first. Correct response: • the symptomatic quadrant last. Explanation: Remediation: Add a Note Question 4 See full question 1m Report this Question A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are You Selected: • rapid, deep breaths and irregular breathing without pauses. Correct response: • progressively deeper breaths followed by shallower breaths with apneic periods. Explanation: Remediation: Add a Note Question 5 See full question 2m 10s Report this Question A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? You Selected: • Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor. Correct response: • Respect the adolescent's wishes and maintain her confidentiality. Explanation: Add a Note Question 6 See full question 2m 33s Report this Question A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? You Selected: • tripod position Correct response: • tripod position Explanation: Remediation: Add a Note Question 7 See full question 2m 28s Report this Question While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do? You Selected: • Ensure that the room is kept warm. Correct response: • Ensure that the room is kept warm. Explanation: Remediation: Add a Note Question 8 See full question 15s Report this Question The nurse is assessing a client's testes. Which finding indicate the testes are normal? You Selected: • soft Correct response: • egg-shaped Explanation: Remediation: Add a Note Question 9 See full question 28s Report this Question The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first? You Selected: • Inspect the lower left extremity. Correct response: • Use a Doppler ultrasound device. Explanation: Remediation: Add a Note Question 10 See full question 1m 22s Report this Question The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action? You Selected: • Assess the client's temperature. Correct response: • Assess the client's temperature. Explanation: Add a Note Question 11 See full question 6m 21s Report this Question A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client? You Selected: • bananas, rice, applesauce, and toast Correct response: • broth, gelatin cubes, and tea Explanation: Remediation: Add a Note Question 12 See full question 26s Report this Question What are important nursing responsibilities when a referral to other health team members has been made for a client? You Selected: • sharing assessment information and information on the client’s capability and level of participation in meeting activities of daily living Correct response: • sharing assessment information and information on the client’s capability and level of participation in meeting activities of daily living Explanation: Add a Note Question 13 See full question 18s Report this Question The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should: You Selected: • expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Correct response: • expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Explanation: Add a Note Question 14 See full question 3m 36s Report this Question The client is admitted to the hospital to rule out duodenal ulcer. The nurse performs the admission history. Which description(s) of pain would be most characteristic of a duodenal ulcer? Select all that apply. You Selected: • Knawing pain after food intake. • Stabbing pain in the RUQ of the abdomen. • Left epigastric pain that awakens the client. Correct response: • Knawing pain after food intake. • Left epigastric pain that awakens the client. Explanation: Remediation: Add a Note Question 15 See full question 23s Report this Question The nurse is managing the care of a client diagnosed with Alzheimer's disease, who is being cared for at home. During a conference with the client's family and multidisciplinary team members, the nurse structures care around which priority nursing diagnosis? You Selected: • impaired swallowing Correct response: • impaired swallowing Explanation: Remediation: Add a Note Question 16 See full question 1m 2s Report this Question The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN? You Selected: • Reminding a client to use the bathroom every 4 hours Correct response: • Administering a client's tube feeding Explanation: Remediation: Add a Note Question 17 See full question 20s Report this Question A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care? You Selected: • bleeding and bruising Correct response: • head injuries Explanation: Remediation: Add a Note Question 18 See full question 41s Report this Question The nurse is determining whether a client is able to manage care at home. A home care referral has been placed. What is the priority assessment by the nurse to determine the client's ability to manage care at home? You Selected: • fall risk score Correct response: • functional age Explanation: Remediation: Add a Note Question 19 See full question 31s Report this Question When assessing the client's level of consciousness following moderate sedation, what would be the appropriate Glasgow Coma Scale score for a client who opens the eyes when the nurse says the client's name, answers questions but is confused, and is able to obey commands and move all extremities? You Selected: • 12 Correct response: • 13 Explanation: Add a Note Question 20 See full question 53s Report this Question What is an expected assessment finding when caring for a client with a percutaneous feeding tube? You Selected: • Dark pink stoma without drainage Correct response: • Dark pink stoma without drainage Question 1 See full question 17s Report this Question A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? You Selected: • "What does the pain feel like?" Correct response: • "What does the pain feel like?" Explanation: Remediation: Add a Note Question 2 See full question 32s Report this Question A nurse correctly identifies which items as belonging to the dorsal cavity? You Selected: • vertebral canal Correct response: • vertebral canal Explanation: Add a Note Question 3 See full question 46s Report this Question The nurse is assessing an older adult’s skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? You Selected: • changes from the normal expected findings Correct response: • changes from the normal expected findings Explanation: Remediation: Add a Note Question 4 See full question 43s Report this Question The nurse is caring for a client who has just had an upper GI endoscopy. The client’s vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next? You Selected: • Promptly assess the client for potential perforation. Correct response: • Promptly assess the client for potential perforation. Explanation: Add a Note Question 5 See full question 14s Report this Question A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? You Selected: • thrombophlebitis Correct response: • thrombophlebitis Explanation: Remediation: Add a Note Question 6 See full question 23s Report this Question A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? You Selected: • Assess the client's level of pain, and administer prescribed analgesics. Correct response: • Assess the client's level of pain, and administer prescribed analgesics. Explanation: Remediation: Add a Note Question 7 See full question 15s Report this Question The nurse is observing a nursing student palpating a client’s maxillary sinuses. The nurse observes that the student has correctly palpated the client’s maxillary sinuses when the student palpates which area? You Selected: • below the client's cheekbones Correct response: • below the client's cheekbones Explanation: Remediation: Add a Note Question 8 See full question 38s Report this Question An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client? You Selected: • Palpate for a rounded swelling above the pubis. Correct response: • Palpate for a rounded swelling above the pubis. Explanation: Remediation: Add a Note Question 9 See full question 36s Report this Question On the 2nd day after surgery, the nurse assesses an older adult client. The nurse finds: • blood pressure is 148/92 mm Hg. • heart rate is 98 bpm. • respirations are 32 breaths/min. • O2 saturation is 88% on 4 L/min of oxygen administered by nasal cannula. • breath sounds are coarse and wet bilaterally with a loose, productive cough. • The client has voided 100 mL very dark, concentrated urine during the last 4 hours. • bilateral pitting pedal edema. Using the SBAR (Situation-Background-Assessment-Recommendation) method to notify the health care provider of current assessment findings, the nurse should recommend which prescription? You Selected: • diuretic medication Correct response: • diuretic medication Explanation: Add a Note Question 10 See full question 19s Report this Question A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client? You Selected: • broth, gelatin cubes, and tea Correct response: • broth, gelatin cubes, and tea Explanation: Remediation: Add a Note Question 11 See full question 30s Report this Question A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? You Selected: • signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes Correct response: • signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes Explanation: Remediation: Add a Note Question 12 See full question 13s Report this Question A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? You Selected: • Level of consciousness, pain level, and wound dressing Correct response: • Level of consciousness, pain level, and wound dressing Explanation: Remediation: Add a Note Question 13 See full question 19s Report this Question A client’s arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation? You Selected: • metabolic acidosis Correct response: • metabolic acidosis Explanation: Remediation: Add a Note Question 14 See full question 28s Report this Question The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? You Selected: • “I took my metformin this morning.” Correct response: • “I took my metformin this morning.” Explanation: Add a Note Question 15 See full question 15s Report this Question The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? You Selected: • Palpate for the bladder above the symphysis pubis. Correct response: • Palpate for the bladder above the symphysis pubis. Explanation: Remediation: Add a Note Question 16 See full question 11s Report this Question The nurse is assessing a client’s deep tendon reflexes. Which graphic shows assessing the biceps reflex? You Selected: • Correct response: • Explanation: Remediation: Add a Note Question 17 See full question 2m 34s Report this Question The client is one day post-op following an abdominal cholecystectomy and reports abdominal pain, The nurse uses the visual analog scale. Which factors will the nurse use to describe the visual analog scale? Select all that apply. You Selected: • Magill pain questionnaire - level 0 - "none" • intensity anchored by "no pain" • 11 point numeric scale - 0 representing "no pain" • 11 point numeric scale - 10 representing "worst pain imaginable" Correct response: • intensity anchored by "no pain" • intensity anchored by "worst imaginable pain" Explanation: Add a Note Question 18 See full question 30s Report this Question When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply. You Selected: • allergies to items other than medications, such as foods and animals • reaction to the allergen • severity of the allergy • allergies to any medications Correct response: • allergies to any medications • allergies to items other than medications, such as foods and animals • reaction to the allergen • severity of the allergy Explanation: Remediation: Add a Note Question 19 See full question 18s Report this Question The charge nurse on a pediatric unit is making clientnassignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? You Selected: • a 4-year-old with chronic graft-versus-host disease who is incontinent Correct response: • a 4-year-old with chronic graft-versus-host disease who is incontinent Explanation: Remediation: Add a Note Question 20 See full question 22s Report this Question The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply. You Selected: • a client who underwent cholecystectomy today • a client with pain related to pancreatitis Correct response: • a client who underwent cholecystectomy today • a client with pain related to pancreatitis Question 1 See full question 9m 34s Report this Question A nurse is performing a preoperative assessment. Which client statement should alert the nurse to the presence of risk factors for postoperative complications? You Selected: • "I've cut my smoking down from two packs to one pack per day." Correct response: • "I've cut my smoking down from two packs to one pack per day." Explanation: Remediation: Add a Note Question 2 See full question 39s Report this Question When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? You Selected: • vesicle Correct response: • vesicle Explanation: Remediation: Add a Note Question 3 See full question 38s Report this Question Why should the nurse avoid palpating both carotid arteries at one time? You Selected: • Palpating both arteries at one time may cause transient hypertension. Correct response: • Palpating both arteries at one time may cause severe bradycardia. Explanation: Remediation: Add a Note Question 4 See full question 1m 1s Report this Question A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature? You Selected: • every 15 minutes Correct response: • every 15 minutes Explanation: Remediation: Add a Note Question 5 See full question 54s Report this Question A client asks the nurse why the prostate-specific antigen (PSA) level is determined before the digital rectal examination. What should the nurse tell the client? You Selected: • "A prostate examination can possibly increase the PSA." Correct response: • "A prostate examination can possibly increase the PSA." Explanation: Remediation: Add a Note Question 6 See full question 13s Report this Question A school nurse is performing an otoscopic examination on an elementary student who states ear pressure. If the nurse suspects a potential diagnosis of otitis media, at which location would the nurse confirm the diagnosis? You Selected: • Your selection and the correct area, market by the green box. Explanation: Remediation: Add a Note Question 7 See full question 9s Report this Question While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis. You Selected: • Your selection and the correct area, market by the green box. Explanation: Remediation: Add a Note Question 8 See full question 1m 7s Report this Question The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? You Selected: • a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Correct response: • a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling Explanation: Remediation: Add a Note Question 9 See full question 49s Report this Question Which sign is an early indication that a client has developed hypocalcemia? You Selected: • tingling in the fingers Correct response: • tingling in the fingers Explanation: Remediation: Add a Note Question 10 See full question 25s Report this Question A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had his dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? You Selected: • "Tell me what you feeling." Correct response: • "Tell me what you feeling." Explanation: Add a Note Question 11 See full question 32m 54s Report this Question The nurse is caring for a client who is post-operative cholecystectomy. When assessing the respiratory status after general anesthesia, which of the following clinical findings would the nurse view as a concern? Select all that apply. You Selected: • cyanosis around the mouth and fingertips • PAO2 of 76 mm Hg Correct response: • PAO2 of 76 mm Hg • cyanosis around the mouth and fingertips Explanation: Remediation: Add a Note Question 12 See full question 46s Report this Question The nurse is caring for an unconscious client recovering from anesthesia. Which position would the nurse place the client in? You Selected: • left lateral recumbent Correct response: • left lateral recumbent Explanation: Remediation: Add a Note Question 13 See full question 1m 9s Report this Question A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? You Selected: • Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Correct response: • Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. Explanation: Remediation: Add a Note Question 14 See full question 4m 34s Report this Question Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client? You Selected: • an 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock Correct response: • a 62-year-old client with a history of Parkinson’s disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Explanation: Remediation: Add a Note Question 15 See full question 48s Report this Question Which client should the nurse assess first? You Selected: • a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache Correct response: • a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain Explanation: Add a Note Question 16 See full question 15s Report this Question Which client should the nurse assess first? You Selected: • a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Correct response: • a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: Add a Note Question 17 See full question 35s Report this Question A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? You Selected: • obtaining a rubella titer on a woman who is planning to start a family Correct response: • obtaining a rubella titer on a woman who is planning to start a family Explanation: Remediation: Add a Note Question 18 See full question 23s Report this Question A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her