1. The nurse is performing a thoracic assessment on a client with chronic
asthma and hyperinflation of the lungs. Which finding should be expected for
this client? ANS >>> Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized client. The nurse
has heard bowel sounds in the right upper quadrant. What action should the
nurse take next? ANS >>> Note the character and frequency of bowel sounds
3. During inspection of a client's mouth and pharynx, the nurse places a
tongue blade on the back of the tongue which causes the client to gag. After
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, removing the tongue blade, what action should the nurse take? ANS >>>
Document an intact gag reflex.
4. When teaching a client how to perform a monthly breast self-assessment,
the nurse should tell the client that it is most important to assess which part
of the breast more closely for changes? ANS >>> Upper outer quadrant.
5. The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45 inches,
and hip measurement of 50 inches. What important message should the nurse
explain to the client to promote health promotion? ANS >>> A waist
circumference is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
6. The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? ANS >>>
Height reduction of 1.5 inches.
7. While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? ANS >>> Sit quietly to allow the client
to respond comfortably.
8. A client is in the clinical for a yearly physical examination. Which action
should the nurse take when preparing to examine the client's abdomen? ANS
>>> Ask the client to urinate before beginning the examination.
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, 9. Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? ANS >>> Bradypnea.
10. Which procedure should the nurse use to assessfor a pulse deficit? ANS
>>> Mea- sure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
11. A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? ANS >>> Dull, thud-like.
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asthma and hyperinflation of the lungs. Which finding should be expected for
this client? ANS >>> Barrel chest
2. The nurse is assessing bowel sounds for a hospitalized client. The nurse
has heard bowel sounds in the right upper quadrant. What action should the
nurse take next? ANS >>> Note the character and frequency of bowel sounds
3. During inspection of a client's mouth and pharynx, the nurse places a
tongue blade on the back of the tongue which causes the client to gag. After
mailto:https://www.stuvia.com/user/techgrades 1/
23
, removing the tongue blade, what action should the nurse take? ANS >>>
Document an intact gag reflex.
4. When teaching a client how to perform a monthly breast self-assessment,
the nurse should tell the client that it is most important to assess which part
of the breast more closely for changes? ANS >>> Upper outer quadrant.
5. The nurse is assessing a postmenopausal client who has a BMI of 32. The
client has a chest measurement of 42 inches, waist measurement of 45 inches,
and hip measurement of 50 inches. What important message should the nurse
explain to the client to promote health promotion? ANS >>> A waist
circumference is greater than 35 inches in women puts you at higher risk for type
2 diabetes and heart disease."
6. The nurse performs a physical assessment on an older female client. Which
change from the prior exam may be an indication of osteoporosis? ANS >>>
Height reduction of 1.5 inches.
7. While conducting an interview to obtain a health history, the nurse notices
that the client pauses frequently and looks at the nurse expectantly. Which
response is best for the nurse to provide? ANS >>> Sit quietly to allow the client
to respond comfortably.
8. A client is in the clinical for a yearly physical examination. Which action
should the nurse take when preparing to examine the client's abdomen? ANS
>>> Ask the client to urinate before beginning the examination.
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23
, 9. Which respiratory condition should the nurse document after measuring a
respiratory rate of 8 breaths/minute? ANS >>> Bradypnea.
10. Which procedure should the nurse use to assessfor a pulse deficit? ANS
>>> Mea- sure the apical pulse and compare it to the peripheral pulse.
*A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
11. A client has been diagnosed with bilateral lower lobe atelectasis. What
percussion sound should the nurse expect to hear when percussing over the
client's lower lobes? ANS >>> Dull, thud-like.
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