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1. A nurse is assessinga client's respiration andnotes they are shallow and at a
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rate of 24/min.The nurse should identify this as which of the following
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unexpected findings?: Tachypnea
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2. A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of
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110/min. The nurse should identify this as which of the following unexpected
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findings?: Tachycardia
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3. A nurse is providing teaching to a client who asks,"What are things that can
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affectmy bloodpressure?"Whichofthe followinginfo shouldthenurse include
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as factors that affect BP?: Time of day, obesity, diuretic medicine, and Smoking
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4. A nurse is conducting a general survey on a client and notes a continuous
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twitching movement of a muscle in the client's left arm. Which of the following
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terms should the nurse use to describe the involuntary movement?: Fascicu-
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lation
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5. A nurse is preparing to obtain a client's height during a general survey. Which
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ofthe followingactionsshouldthe nurse take?:Ensuretheclient'sfeet are in contact
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with the wall or measuring pole.
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6. A nurse is documenting a client's vital signs in the medical record following a
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general survey. Which of the following entries should the nurse place in the
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record?: Oxygen saturation 96% on oxygen 2 L/min via cannula
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7. A nurse is preparing to conduct an initial survey and assessment on a newly
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admitted client.Which of the following actions should the nurse plan to take?:
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Engage in active listening with the clientand allow the clientto express concerns early
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in the assessment process
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8. A nurse is having difficulty obtaining a pulse oximetry reading from a client. The
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nurse should identify that which of the following factors can interfere with
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obtaining a pulse ox reading?: Recent scan with contrast dye
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9. Anurseisadmittingaclientwhois162.6cm(64in.)tallandweighs68.2kg (150 lb).
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Using the BMI table shown what is the client's BMI?: B.25
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10. A nurse is conducting a general survey on a client who is being admitted to a
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long-term care facility..The nurse is assessing the client's emotional state.
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Whichofthefollowingfindingsshouldthenurserecordasasubjective,
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unexpected finding?:The client reports they feel sad and lonely most of the time
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11. A nurse is completing an initial assessment checklist on an older adult client.
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Theclientisaccompaniedbytheircaregiver.Forwhichofthefollowing indicators
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should the nurse observe when assessing for potential maltreat- ment of the
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client?: Dirty clothing, unexplained physical injuries, malnourished appearance
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