The student nurse measures the client’s oxygen saturation level by using a pulse oximeter, and confers with the nurse preceptor after completion. Which statement by the student indicates the need for further education? 1. “A normal finding is that the client’s oxygen saturation level is above 70%.” 2. “The pulse oximeter can measure the oxygen saturation of the hemoglobin.” 3. “I placed the sensor on the client’s finger.” 4. “This test is noninvasive and painless.” .
The client is recovering from orthopedic surgery on a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions will the nurse include in the teaching session? Standard Text: Select all that apply.
1. Provide a body framework. 2. Provide movement. 3. Maintain posture. 4. Generate heat. 5. Calcium storage. .
During the examination of a male client’s scrotum the nurse detects a hardened area in the right side of the scrotal sac. Which is the priority nursing action based on this finding? 1. Ask the client about voiding patterns. 2. Notify the healthcare provider of this finding. 3. Use a light to perform transillumination. 4. Ask the client about sexual practices. .
The nurse is examining the external genitalia of a female client and notes draining papules. Based on this data, which condition does the nurse suspect? 1. Genital warts. 2. Herpes infection. 3. Syphilitic lesion. 4. Contact dermatitis.
The student nurse is preparing to insert the otoscope into the adult client’s ear. Which statement by the student nurse indicates the need for further education? 1. “I’m going to use the largest speculum that will fit easily into the ear canal.” 2. “I’m going to prepare to insert the otoscope by pulling the pinna down and back.” 3. “The tympanic membrane should look gray and translucent.” 4. “I will ask the client to perform the Valsalva maneuver so that I can see how well the tympanic membrane moves.”.
The nurse is preparing to interview the older adult client and perform a head-to-toe assessment. Which actions by the nurse are appropriate? Standard Text: Select all that apply. 1. The nurse has requested that the client put on a cotton gown prior to the interview. 2. The nurse seats the client so that the light from the window faces the client with the nurse’s back to the window. 3. The nurse addresses the client by her first name. 4. The nurse maintains eye contact; both nurse and client are seated. 5. During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.
The nurse is interviewing the client and learns that the client has an open leg wound that has been draining a moderate amount of yellowish drainage over the last 3 days. Prior to assessing the client’s wound, which piece of personal protective equipment is most important for the nurse to wear based on the principles of standard precautions? 1. Fluid-resistant gown. 2. Shoe covers. 3. Mask. 4. Gloves. .
While conducting a rapid assessment for a client who has diabetes, the student nurse notes that the client is experiencing emotional stress following the recent death of the spouse. When discussing the client with the nurse preceptor, which statement by the student nurse student indicates the need for further education? 1. “Emotional stress can negatively impact the immune system’s ability to function.” 2. “The client has probably not been eating well recently.” 3. “I should not ask about the use of drugs or alcohol at this time.” 4. “The client may be hyperglycemic.” .
The nurse is examining an adolescent female and notes no pubic hair on the pubis area. Based on this data, which action by the nurse is appropriate? 1. Ask the client if she is menstruating. 2. Examine the client for breast buds 3. Report the findings to the healthcare provider. 4. Document the findings as abnormal.
The nurse is assessing the function of the client’s cranial nerve XII (hypoglossal). Which activity will allow the nurse to assess this nerve during the client’s physical assessment? 1. “Can you stick out your tongue?” 2. “I’m going to ask you to taste something and tell me what you think it is.” 3. “Close your eyes and tell me when you feel me touch your face with this wisp of cotton.” 4. “I’m going to lightly touch the back of your throat with this tongue depressor.” .
The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client? 1. Skin integrity impairment. 2. Self-care deficit. 3. Self-esteem, situational-low. 4. Infection. .
The nurse is performing a focused interview with an older adult client. Which statements indicate the client has an increased risk of developing depression? Standard Text: Select all that apply 1. “I’ve been so lonely since my wife, Maggie, passed away 2 months ago.” 2. “My mother had a history of depression.” 3. “I was diagnosed with chronic bronchitis 4 years ago.” 4. “My son visits at least once a week and takes care of my financial stuff.” 5. “I visit my sister every Monday and she makes me dinner.”.
The nurse notes an exaggerated lumbar curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record? 1. Lordosis. 2. Scoliosis. 3. Kyphosis. 4. Flattened curve.
The nurse is conducting a health interview for a 55-year-old client who presents to the clinic for an annual physical examination. The client questions the need to begin screening for prostate cancer at this examination. Which response by the nurse is the most appropriate? 1. “Unless you are at an increased risk for the development of prostate cancer no additional screening indicated.” 2. “PSA screening tests should be performed once you reach age 75.” 3. “You need to begin having an annual prostate examination.” 4. “A cystoscopy should be performed annually to assess for prostate changes at age 55.”.
The nurse is discussing the results of recent laboratory tests with a female client, who tested positive for a sexually transmitted infection. Which statement by the nurse is the most therapeutic? 1. “If you did not sleep around, this would not be happening.” 2. “The best way to prevent this from happening again is to not have sex until you are married.” 3. “I understand that this result is concerning. I would like to discuss how to prevent this from occurring again.” 4. “You may never be able to have children because of this diagnosis.” .
The nurse is performing a physical assessment on a client in an outpatient clinic. The nurse is inspecting and palpating the client’s face, skin folds, axillae, palms, and soles of the feet. The nurse determines the client is diaphoretic. Which client statement supports this finding? Standard Text: Select all that apply. 1. “Your elevator is out and I had to climb three flights of stairs.” 2. “I’ve been running a fever for the last few days.” 3. “I think I have hypothyroidism.” 4. “I’m in a lot of pain today.” 5. “I heard a rumor at work yesterday that layoffs were inevitable.” .
A client asks the nurse, “What’s the purpose of the liver?” Which statements will the nurse include in the response to this client’s question? Standard Text: Select all that apply. 1. “It helps you digest fats.” 2. “It is an endocrine and exocrine gland.” 3. “It filters waste from the blood and makes urine.” 4. “It makes some blood-clotting substances.” 5. “It can help you store certain vitamins.”.
A client comes to the emergency department (ED) complaining of a painful injury to the right knee received while playing basketball. Which examination techniques will the nurse include during the physical assessment of this client? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Bulge sign testing. 4. Ballottement. 5. Percussion.
The healthcare provider is performing an assessment on a pregnant client. The examiner notes a softening in the area being assessed. Which probable sign of pregnancy is being assessed? 1.Goodell sign. 2. Hegar sign. 3. Chadwick sign. 4. Ladin sign. .
The nurse is performing a neurological assessment and needs to assess for vibration, as well as sharp and dull sensation. Which objects will the nurse use to complete this assessment? Standard Text: Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball. 5. Tongue blade.
The nurse is measuring the urinary output for a client and notes 450 ml of urine. Which conclusion by the nurse is the most appropriate? 1. Decreased from normal. 2. Concentrated from what is normal. 3. Increased from normal. 4. Normal amount. .
The nurse is examining a female client and notes a greenish discharge with a foul odor. The client also exhibits guarding of the abdomen. Based on this data, which diagnosis does the nurse anticipate? 1. Trichomoniasis. 2. Herpes infection. 3. Gonorrhea. 4. Bacterial vaginosis.
The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which is appropriate for the nurse to use when documenting this finding in the medical record? 1. Hyperreflexia. 2. Babinski response. 3. Brudzinski sign. 4. Nuchal rigidity.
The nurse is performing the Romberg test and asks the client to stand with the feet together and eyes closed. The nurse notes the findings are normal. Which finding is expected during this assessment? 1. Swaying from side to side. 2. Exhibiting minimal swaying. 3. Feeling moderately dizzy. 4. Having complete loss of balance. .
The nurse is planning a program to promote Healthy People 2020 focus areas relating to osteoporosis. Which program would appropriately serve as primary prevention? Correct Answer: 3 1. The development of a program to address available medication therapies for the individual with osteoporosis. 2. Community screening programs to identify individuals who have early onset osteoporosis. 3. Community education programs to discuss methods that can be implemented to reduce the chance of developing osteoporosis. 4. The development of community support programs for individuals who have been diagnosed with osteoporosis.
The nurse notes that a client has difficulty with ambulation due to an unsteady gait. Which term will the nurse use to document this finding in the medical record?
1. Flaccidity. 2. Paralysis. 3. Hemiparesis. 4. Ataxia. .
The nurse is preparing to examine the reproductive system for a male client recently admitted to the medical unit. Which techniques does the nurse plan to incorporate into this physical assessment? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Aspiration.
The nurse is speaking with the client during the focused interview. The client states, “My doctor said that my spleen was enlarged. Where is my spleen?” Which location will the nurse point to when answering this client’s question?
1. A 2. B 3. C 4. D.
After a vaginal examination, the nurse suspects the client has a gonorrheal infection. Based on this suspicion, which is the priority action by the nurse? 1. Counsel regarding safe sex practices. 2. Obtain history of sexual contacts. 3. Obtain a culture. 4. Document the findings.
The nurse is performing a focused interview with an older adult client. Which statements by the client are expected? Standard Text: Select all that apply. 1. “I have been having loose stools every day for the last 3 years.” 2. “I know I just don’t drink as much water as I should.” 3. “My belly seems softer and flabbier as I get older.” 4. “My mouth is always dry.” 5. “My heartburn gets worse the older I get.” .
The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings are scored using the best motor response portion of the scale? Standard Text: Select all that apply 1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated.
During the physical assessment, the hospitalized client states, “I’ve been under an incredible amount of stress since my healthcare provider diagnosed me with colon cancer 2 days ago.” Which assessment data collected by the nurse are associated with increased stress? Standard Text: Select all that apply. 1. Apical heart rate is 104 beats per minute. 2. Respiratory rate is 16 breaths per minute. 3. Pupils were equal, dilated, and round. 4. Client is hypoglycemic. 5. Blood pressure is 158/94.
The client is recovering from orthopedic surgery on a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions will the nurse include in the teaching session? Standard Text: Select all that apply.
1. Provide a body framework. 2. Provide movement. 3. Maintain posture. 4. Generate heat. 5. Calcium storage.
The nurse is conducting an initial respiratory assessment on the client recently admitted to the unit. Rank the following steps in the correct sequence. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. 1. The nurse percusses the client’s thorax. 2. The nurse unties the client’s gown to better visualize the client’s thorax. 3. The nurse warms his stethoscope and listens to the client’s lung sounds in each lung field. 4. The nurse gently palpates the client’s thorax. 5. 2, 4, 1, 3.
The student nurse measures the client’s oxygen saturation level by using a pulse oximeter, and confers with the nurse preceptor after completion. Which statement by the student indicates the need for further education? 1. “A normal finding is that the client’s oxygen saturation level is above 70%.” 2. “The pulse oximeter can measure the oxygen saturation of the hemoglobin.” 3. “I placed the sensor on the client’s finger.” 4. “This test is noninvasive and painless.” .
The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client’s assessment data, which conditions does the nurse suspect? Standard Text: Select all that apply. 1. Constipation. 2. Appendicitis. 3. Cholecystitis. 4. Small bowel obstruction. 5. Peritonitis. .
The nurse has palpated an abnormal mass within the client’s scrotum. Which assessment activity is appropriate for the nurse to perform next? 1. The nurse should percuss the client’s scrotum. 2. The nurse should attempt to transilluminate behind the area in which the abnormal mass was palpated. 3. The nurse should inspect the inguinal area. 4. The nurse should gently squeeze the mass between the fingers. .
The nurse is preparing to examine the reproductive system for a male client recently admitted to the medical unit. Which techniques does the nurse plan to incorporate into this physical assessment? Standard Text: Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Aspiration.
The nurse percusses the client’s abdomen. Which piece of information accurately reflects that tympany is present? 1. “The sound is low-pitched, loud, and hollow-sounding.” 2. “It is a high-pitched, soft sound that doesn’t last very long.” 3. “The sound is very loud and has a low tone. 4. “It sounds like a drum, is loud, and high-pitched.”.
A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which client statement would require further teaching? 1. “I need to perform self-catheterization three times daily.” 2. “I know I cannot look to see if my bladder is full.” 3. “I need to avoid bladder distention.” 4. “I’ll drink adequate amounts of liquids.” .
The school nurse is assessing adolescent females for scoliosis. Which area of the spine does the nurse plan to assess?
1. A 2. B 3. C 4. D.
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