BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM QUESTIONS AND VERIFIED ANSWERS |100% CORRECT| GRADE A+

BSN 246 HESI HEALTH ASSESSMENT UPDATED EXAM QUESTIONS AND VERIFIED ANSWERS |100% CORRECT| GRADE A+ “The nursing process offers a framework to identify needs, create a plan of care, and determine the effectiveness of interventions. Which of the following stages of the nursing process involves the assessment of which interventions were successful and which ones were not? a.Assessment b.Diagnosis c.Planning d.Evaluation - CORRECT ANSWER D. Evaluation" "Which nurse is performing the technique of light palpation appropriately? a) Nurse A applies the bimanual technique to determine size and location of the patient's heart. b) Nurse B uses the fingertips to feel for temperature differences on the patient's legs. c) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations. d)Nurse D depresses the patient's abdomen approximately 4 cm to assess pulsations. - CORRECT ANSWER c) Nurse C places the ulnar surface of the hands on the patient's thorax to detect vibrations." "A patient has been complaining of abdominal cramping and gas; the nurse notes that his abdomen is slightly distended. Which sound does the nurse expect to hear during percussion of this patient's abdomen? a) Flatness b) Dullness c) Resonance d) Tympany - CORRECT ANSWER d) Tympany" "A nurse is using the finger pads to palpate a patient's dorsalis pedis pulses and is unable to feel any pulses. Which action is appropriate for the nurse to perform next? a) Document that the dorsalis pedis pulses are not palpable. b) Have the patient stand and try again to palpate the pulses. c) Use a Doppler to detect the presence of the pulses. d) Palpate the dorsalis pedis pulses using the ulnar surface of the hand. - CORRECT ANSWER c) Use a Doppler to detect the presence of the pulses." "A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder? a) Depression b) Schizophrenia c) Bipolar disorder d) Anxiety disorder - CORRECT ANSWER Depression" "While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation? a) AUDIT screening tool b) Rapid eye test c) Mental status examination d) Holmes Social Readjustment Rating Scale - CORRECT ANSWER a) AUDIT screening tool" "*A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds? A. Use the bell of the stethoscope to listen to the lung fields over lower lobes. B. Have the client lay flat while listening to the anterior surface of the chest. C. Press the stethoscope's diaphragm firmly on the skin over each lung field. D. Shave all chest hair that may distort sounds heard through the diaphragm. - CORRECT ANSWER C. Press the stethoscope's diaphragm firmly on the skin over each lung field." "A patient complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what of the following findings will suggest that the cause of this patient's dyspnea is due to heart disease rather than respiratory disease? a) Increased anteroposterior diameter b) Clubbing of the fingers c) Bilateral peripheral edema d) Increased tactile fremitus - CORRECT ANSWER c) Bilateral peripheral edema" "A nurse is auscultating the lungs of a healthy male patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? a) Make sure the bell of the stethoscope is used, rather than the diaphragm. b) Hold stethoscope firmly to prevent movement when placed over chest hair. c) Ask the patient not to talk while the nurse is listening to the lungs. Change the patient's position to ensure accurate sounds. - CORRECT ANSWER b) Hold stethoscope firmly to prevent movement when placed over chest hair." "Which description of pain from the patient makes a nurse suspect the patient's pain is originating from a muscle? a) "Crampy" b) "Dull and deep" c) "Boring and intense" d) "Sharp upon movement" - CORRECT ANSWER a) "Crampy"" "A patient asks, "Why is touching my toes necessary? This is a sports physical examination, not exercise class." What is the most appropriate response by the nurse? a) "This is the best way to check for symmetry of your arms." b) "I am looking at the stretch of your ham strings." c) "This allows me to see how straight your spinal column is." d) "I am assessing the rotation of your spine." - CORRECT ANSWER c) "This allows me to see how straight your spinal column is."" "When assessing a patient's level of consciousness, what should the nurse assess first? a.Level of alertness b.Orientation to person c.Orientation to place d.Orientation to time - CORRECT ANSWER a.Level of alertness" "*A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate? *A. A normal reflex response. B. Absent or sluggish response consistent with a lower motor neuron lesion. C. Flaccid paralysis. D. Hyperactive response consistent with an upper motor neuron disorder. - CORRECT ANSWER D. Hyperactive response consistent with an upper motor neuron disorder." "A nurse assesses a patient with a head injury who has slowing intellectual functioning, personality changes, and emotional lability. The nurse correlates these findings with which area of the brain? a) Frontal lobe b) Parietal lobe c) Thalamus d) Temporal lobe - CORRECT ANSWER a) Frontal lobe" "A patient reports having difficulty swallowing. Based on this information, how does the nurse assess the appropriate cranial nerve? a) Ask the patient to stick out the tongue and move it in all directions. b) Ask the patient to move the head to the right and left. c) Observe the symmetry of the face when the patient talks. d) Assess for taste on the anterior part of the tongue. - CORRECT ANSWER a) Ask the patient to stick out the tongue and move it in all directions." "the nurse is caring for a client just admitted to the mental health unit the client is displaying immobile and mute behaviors and is withdrawn. the client is lying on the bed in a fetal position. which is the most appropriate nursing interventions? a. ask direct questions to encourage talking b. leave the client alone so as to minimize external stimuli c. sit beside the client in silence with occasional open ended questions d. take the client into the dayroom with other clients so that they can help watch the client - CORRECT ANSWER c. sit beside the client in silence with occasional open ended questions" "the nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. which assessment findings would the nurse expect to note? SATA a. dental decay b. moist, oily skin c. loss of tooth enamel d. electrolyte imbalances e. body weight well below ideal range - CORRECT ANSWER a. dental decay c. loss of tooth enamel d. electrolyte imbalances" "the nurse is monitoring a hopsitalized client who abuses alcohol. which findings would alert the nurse to the potential for alcohol withdrawal delirium? a. hypotension, ataxia, hunger b. stupor, lethargy, muscle rigidity c. hypotension, coarse hand tremors, lethargy d. hypertension, changes in level of consciousness, hallucinations - CORRECT ANSWER d. hypertension, changes in level of consciousness, hallucinations" "a moderately depressed client who was hopsitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. the client says to the nurse "I'm finally cured." how would the nurse interpret this behavior as a cue to modify the treatment plan? a. suggesting a reduction in medication b. allowed increased "in room" activities c. increasing the level of suicide precautions d. allowing the client off-unit privileges as needed - CORRECT ANSWER c. increasing the level of suicide precautions" "the nurse is performing an assessment on a client with dementia. which piece of data gathered during the assessment indicates a manifestation associated with dementia? a. use of confabulation b. improvement in sleeping c. absence in sundown syndrome d. presence of personal hygenic care - CORRECT ANSWER a. use of confabulation" "which client is at greatest risk for committing suicide? a. a client with metastatic cancer b. a client with a newly diagnosed cardiac disorder c. a client who just had an argument with the fiance d. a newly divorced client who states has custody of the children - CORRECT ANSWER a. a client with metastatic cancer" "the nurse is performing an admission assessment on a client at high risk for suicide. which assessment question will best elicit data related to this risk? a. "what are you feeling right now?" b. "do you have a plan to commit suicide?" c. "how many times have you attemped suicide int he past?" d. "why were your attemps at suicide unsuccessful in the past?" - CORRECT ANSWER b. "do you have a plan to commit suicide?"" "the nurse notes documentation that a newly admitted client experiences flashbacks. what diagnosis would this notation support? a. anxiety b. agoraphobia c. PTSD d. schizophrenia - CORRECT ANSWER c. PTSD" "when would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? a. administered medication has taken effect b. the client verbalizes the reasons for the violent behavior c. the client apologizes and tells the nurse that it will never happen again d. no aggressive behavior has been observe for 1 hour afrter the release of two of the extremity restraints - CORRECT ANSWER d. no aggressive behavior has been observe for 1 hour afrter the release of two of the extremity restraints" "the nurse is performing an assessment on a client with a fiagnosis of left side heart failure, which assessmnet component would elicit specfic information regarding the clients left sided heart function? a. listening to lung sounds b. palpating for organomegaly c. assessing for JVD d. assessing for peripheral and sacral edema - CORRECT ANSWER a. listening to lung sounds" "a 56 year old client with heart failure is taking digoxin for treatment of the health problem. the nurse ausculatates the clients apical HR before admin, digoxin and the HR is 52 bpm. the nurse would interpret this as? a. normal, because of age b. abnormal, requiring further assessment c. normal, as a result of digoxin d. normal, bc this is the reason he is getting digoxin - CORRECT ANSWER b. abnormal, requiring further assessment" "a client recovering from an exacerbation of left sided heart failure is experiencing activity intolerance. which change in vitals during activity would be the best indicator that the client is tolerating mild excercise? a. oxygen saturation decreased from 96% to 91% b. pulse rate increased from 80 to 104 bpm c. bp decreased from 140/86 to 112/72 mm hG d. RR increased from 16 to 19 bpm - CORRECT ANSWER d. RR increased from 16 to 19 bpm" "the nurse notes that a clients cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. how would the nure interpret this rhythm? a. bradycardia b. tachycardia c. atrial fibrillation d. normal sinus rhythm (NSR) - CORRECT ANSWER c. atrial fibrillation" "A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks 4.Eliminating sources of caffeine from meal trays - CORRECT ANSWER 4.Eliminating sources of caffeine from meal trays" "the nurse is conducting a health history of a client with a primary diagnosis of heart failure. which conditions reported by the client could play a role in exacerbating the heart failure? SATA a. emotional stress b. AFIB c. nutrtional anemia d. peptic ulcer disease e. recent upper resp. infection - CORRECT ANSWER a. emotional stress b. AFIB c. nutrtional anemia e. recent upper resp. infection" "the nurse is preparing to care for a burn client schedueld for an escahrotomy procedure being perofmed for a third degree dcircumferential arm burn. the nurse understand that which finding is the anticipated therapeutic outcome of the escharotomy? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue - CORRECT ANSWER a. return of distal pulses" "The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding? A. Document this normal bowel sound activity in the record. B. Encourage increased consumption of fiber in the diet. C. Observe the next bowel movement for signs of bleeding. D. Report the hyperactivity to the healthcare provider. - CORRECT ANSWER Correct answer is A. Normal Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (Loud prolonged gurgle) may be hear." "In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? A. Eyelids are matted and crusted. B. Cornea are jaundiced. C. Oral mucosa is cyanotic. D. Face is flushed and diaphoretic. - CORRECT ANSWER Answer is C. Blue lips occur when the skin on the lips takes on a bluish tint or color. This generally is due to either a lock of oxygen in the blood or to extremely cold temperatures. When the skin becomes a bluish color, the symptom is called cyanosis. Most commonly, blue lips are caused by a lack of oxygen in the blood. Most causes of cyanosis are serious and symptom of your body not getting enough oxygen. Over time, this condition will become life-threatening. It can lead to respiratory failure, heart failure, and even death, if left untreated." "While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirators are regular and deep, and his respiratory rate is 14 breaths/minutes. What is the best nursing action? A. Ask the client to perform light exercise and observe the respiratory effect. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail. D. Explain to the client the possible causes of dyspnea or "shortness of breath." - CORRECT ANSWER Correct answer is C. Both respiratory rate and breath sounds are normal. Further assessment is needed by asking the client to describe his SOB" "When assessing a male client's respiratory status, which technique should the nurse use to assess his anterior- posterior (AP) chest diameter? A. Auscultation. B. Percussion. C. Palpation. D. Observation. - CORRECT ANSWER Correct answer is D. Observation is the way to detect barrel chest which is associated with COPD" "Which assessment finding supports the client statement, "My feet swell all the time?" A. 2+ pitting edema of ankles bilaterally. B. Capillary refill both feet > 3 seconds. C. Pedal pulses weak and thread. D. Positive Homan's sign bilaterally. - CORRECT ANSWER Correct answer is A. 2+ pitting edema indicate swelling in the lower extremities. Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg. A positive Homans's sign (calf pain at dorsiflexion of the foot) is thought to be associated with the presence of thrombosis." "The nurse is performing a cranial nerve exam on an 87-year-old client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. What action should the nurse take next? A. Review past history for any episodes of a cerebral cortex lesion. B. Implement neuro vital signs every 2 hours to detect Cushing's Triad. C. Continue the assessment to the next pairs of cranial nerves. D. Assess the spinal reflexes for demyelination symptoms. - CORRECT ANSWER Correct answer is C. Full cranial nurses assessment should be completed before considering the other options." "When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment? A. PERRL. B. GCS of 15. C. PERLA. D. Neuro status intact - CORRECT ANSWER Correct answer is A. "Pupils Equal, Round, and Reactive to Light"." "Which assessment technique provides the nurse with the best data related to the client's level of peripheral perfusion? - CORRECT ANSWER correct answer C. Capillary refill test" "The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs. - CORRECT ANSWER Correct answer is D. A focused assessment collects relevant information pertaining to the current condition of the patient after a change or new symptom develops." "The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. What question should the nurse ask first? "Have you A. Been depressed lately?" B. Had everything to eat in the last 24 hours?" C. Ever had problems with you blood sugar?" D. Been sleeping well?" - CORRECT ANSWER Correct answer is D. To rule out symptoms for lack of sleep, asking the client if he slept well would help determining why he has the presented symptoms." "After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the nurse take? A. Brighten the light in the client's room. B. Assess the client's visual fields. C. Review the client's medication list. D. Administer PRN saline eye solution. - CORRECT ANSWER Correct answer is B. PERRLA: Accommodation is the following step which refers to your eyes' ability to see things that are both close up and far away." "The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client? A. Masses. B. Peristaltic waves. C. Heterogeneous color. D. Homogeneous color. - CORRECT ANSWER Correct answer is D. Symmetry is a great value of normal body imagine while performing inspection." "Which skill should the nurse have an older client demonstrate to evaluate performance of daily living activities? A. Opening a bar soap package. B. Sorting a collection of socks. C. Reading a short paragraph. D. Telephoning a family member. - CORRECT ANSWER Correct answer is B. ADL is used as an indicator of a person's functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life." "A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist? A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge D. Diminished ability to focus on close work and excessive illumination required. - CORRECT ANSWER Correct answer is D. Diminished ability to focus on close work could be a sign of cranial nerve damage and could lead to reduced visual acuity, due to a reduced ability of the lens in the eye to focus light on the retina, results in images that appear blurry." "To assess a female client for hirsutism, which action should the nurse take? A. Lightly palpate over the client's entire scalp. B. Apply and release light pressure to the skin. C. Assess the appearance of the client's face. D. Observe the hair shafts on the client's scalp - CORRECT ANSWER Correct answer is C. Hirsutism is a condition in women that results in excessive growth of dark or coarse hair in a male-like pattern like face, chest and back." "An older adult client is admitted to the medical unit because of loss of appetite and generalized malaise. To analyze the client medical condition, which laboratory value is most important for the nurse to review? A. Hematocrit. B. Serum Calcium. C. Hemoglobin. D. Serum pre-albumin - CORRECT ANSWER Correct answer is C. Hemoglobin is the main lab value to check for anemia. Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe." "A male client returns to the clinic for a follow-up visit after being treated for a bladder infection. While examining the client, which finding indicated an expected response to the treatment? A. Orange sized prostate gland. B. Post-voided residual volume of 50 mL. C. Pain score of 1 out of 10 with urination. D. Decreasing sperm cell count. - CORRECT ANSWER C" "The nurse completes palpitation of the abdomen on an older adult client. Which finding is considered normal for the client? A. Non-tender. B. Gallop. C. Thrill. D. Peristaltic waves. - CORRECT ANSWER Correct answer is D. The small intestine undergoes segmental contractions and peristaltic waves Segmental contractions occur for short distances only along the small intestine Peristaltic waves occur for variable distances to cause the chyme to move along the small intestine." "The nurse has just completed palpitation maneuvers for lymph nodes on a 75-year-old female client. Which findings are considered normal for this elderly client? A. Nodes are non-palpable. B. Axillary nodes feel soft and fatty. C. Nodes feel ropey and rubbery. D. Inguinal nodes are enlarged and warm to the touch. - CORRECT ANSWER Correct answer is A. Normal lymph nodes are non-palpable." "A women comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the women begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide? A. "Why don't I come back in a few minutes after you are more composed." B. Offer a tissue and sit quietly until the crying subsides. C. Allow the client to compose herself then change the subject. D. "I'm so sorry that I made you cry. I didn't mean to upset you." - CORRECT ANSWER Correct answer C. Try always to listen to the patient when she is in a bad mood or wants to express her feeling." "While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take? A. Apply warm blankets to both feet. B. Palpate pulse points with legs dependent. C. Notify the healthcare provider. D. Use a doppler ultrasonic stethoscope. - CORRECT ANSWER Correct answer is D. Doppler ultrasonic stethoscope is used when the nurse couldn't palpate a pedal pulse of a client." "A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is complaining of pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first? A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake. - CORRECT ANSWER Correct answer is A. Since it is a single leg, the nurse has to rule out any trauma of infection especially the left side for the patient is awakened." "The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? A. Defer the thyroid exam and observe the client for signs of myxedema. B. Document that thyroid gland size is normal with no visible goiter. C. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland. - CORRECT ANSWER Correct answer is C. To palpate a client thyroid gland: Use one hand to slightly retract the sternocleidomastoid muscle while using the other to palpate the thyroid. Have the patient swallow a sip of water as you palpate, feeling for the upward movement of the thyroid gland." "While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus? A. Increased pigmentation and coarse skin. B. Flap of tissue at sphincter. C. Hypotonic tone of the anal sphincter. D. Dimpled area above anus. - CORRECT ANSWER Correct answer is A" "Which focused assessment technique should the nurse use for a client admitted with possible dehydration? A. Press skin over a bony prominence. B. Grasp skin fold of the posterior forearm. C. Check hands for parchment-like appearance. D. Measure the circumference of the calf. - CORRECT ANSWER Correct answer is B. Skin turgor is assessed by firsts grasping a fold of skin on the back of a patient's hand" "The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? (Select all that apply) A. Osteopenia. B. Kyphosis. C. Atrophy. D. Contracture. E. Crepitus - CORRECT ANSWER Correct answers are B, C, and D." "A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming today. To assist normal range of motion (ROM) of the client's shoulder, which assessment techniques should the nurse ask the client to perform? A. Alternate both index fingers to tough the tip of nose accurately. B. Extend arms up to 180 degrees besides the ears. C. Extend arms straight out and hold without drifting. D. Hold arms up at 90 degree while arms are pushed downward - CORRECT ANSWER Correct answer is D." "A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Collect information about the client's activities since surgery. - CORRECT ANSWER Correct answer is D." "In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. What should the nurse do next? A. Notify the healthcare provider. B. Observe for eye opening to a painful stimulus. C. Check the pupillary response to light. D. Ask the client to open his eyes - CORRECT ANSWER Correct answer is C." "In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment? A. Darken the client's room environment. B. Cover the client with a warmed blanket. C. Measure the client's body temperature. D. Instruct the client to close both eyes. - CORRECT ANSWER Correct answer is B" "The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire. D. Cessation of menstruation. - CORRECT ANSWER correct answer is A" "A client states that he is legally blind. Which assessment techniques should the nurse use to obtain data to support the client's statement? A. Observe the client's optic disc through an ophthalmoscope. B. Assess the client's ability to read a Snellen chart from a distance of 20 feet. C. Observe the client's pupillary response to a penlight. D. Observe the client's eye movements through the cardinal fields of vision. - CORRECT ANSWER correct answer B." "Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough? D. What medications have you used for your cough? - CORRECT ANSWER Correct answer is A. The nurse should always ask general questions about medication which include OTC and herbal products. Also, there might be other medications that cause cough like ACE inhibitors so the nurse should assist the who image." "After a young adult woman describes feeling palpitations when she lies on her left side it is most important for the nurse to auscultate heart sounds at which anatomical location? A. Second intercostal space, left of the sternal border. B. Left third intercostal space, left lateral sternal border. C. Base of the heart at second intercostal space, right of the sternal border. D. Apex of the heart at the left fifth intercostal space at the midclavicular line - CORRECT ANSWER Correct answer is D. The apex beat or apical impulse is the palpable cardiac impulse farthest away from the sternum and farthest down on the chest wall, usually caused by the LV and located near the midclavicular line (MCL) in the fifth intercostal space" "While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth. - CORRECT ANSWER Correct answer is A. Elevation of the legs decreases welling and helps with blood flow." "During an abdominal assessment, a client with a temperature of 103 F (39.4 C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement? A. Electrocardiogram. B. Complete bed rest. C. Monitor urinary output. D. Nothing by mouth. - CORRECT ANSWER Correct answer is D." "After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. What action should the nurse implement? A. Use the bell of the stethoscope to auscultate again. B. Elevate the head of the client's bed immediately. C. Document the presence of borborygmi. D. Auscultate the remaining two quadrants. - CORRECT ANSWER Correct answer is D. Full assessment of all parts of the lungs, side by side, should be performed before taking any other action or document the findings." "To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take? A. Ask the client to describe any other related symptoms. B. Use both hands to hold and palpate the client's hands. C. Lightly pinch a fold of skin over the client's sternum. D. Place the dorsum of the hand on the client's forehead. - CORRECT ANSWER Correct answer is B." "A male client who is admitted for an acute brain attack reports the onset of a burning sensation in his hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia? A. Evaluate client's muscle strength and hand grips. B. Observe skin for erythema, edema, and warmth. C. Review the client's serum electrolytes. D. Check distal phalanges capillary refill - CORRECT ANSWER Correct answer is A." "A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis? A. Purulent secretions from eyes and nares. B. Eye tearing and thick yellow nasal drainage. C. Snoring and bilateral, pale gray nodules. D. Intranasal edema and swelling of turbinates. - CORRECT ANSWER Correct answer is D." "To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take? A. Observe the appearance of the thorax. B. Auscultate the client's breath sounds. C. Percuss diaphragmatic excursion. D. Palpate tactile fremitus on the posterior chest - CORRECT ANSWER Correct answer is A. The chest takes on a barrel-like appearance called a "barrel chest." A barrel chest forms because your lungs are chronically overfilled with air and can't deflate normally. This causes your rib cage to be partially expanded at all times. This is common in COPD patients." "When auscultating a client's lung sounds, the nurse hears rhonchi in the upper lung fields anteriorly. Which action should the nurse take first? A. Measure capillary refill. B. Ask the client to cough. C. Monitor oxygen saturation. D. Document the finding. - CORRECT ANSWER Correct answer is B. Many abnormal breath sounds are best heard asking the patient to cough." "During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record? A. Proximal intertarsal join swelling of big toe. B. Non-painful enlarged interphalangeal joints. C. Distal interphalangeal joint nodules that deviate. D. Frozen, non-movable phalangeal joints. - CORRECT ANSWER correct answer is C. Heberden nodes (hard or bony swelilngs in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis." "The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dying my hair for so long, I'm not even sure,,,, I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair? A. Excess vellus hair. B. Receding front hairline. C. Fine, thin, limp texture. D. Coarse, dry, brittle texture. - CORRECT ANSWER Correct answer is D. Excessive dying of the hair will lead the hair to be coarse and dry." "The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain". Which question should the nurse ask the adolescent first? A. "Have you taken any medications to relieve the pain?" B. "What were you doing when you first noticed the problem?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?" - CORRECT ANSWER Correct answer is C. Scoliosis (a severe curvature of the spine) is a possible cause of back pain, especially in adolescent girls. Your pediatrician evaluates your child's posture during regular well-child visits to make sure her back is straight and she's growing normally." "During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client body mass index (BMI) as 16. Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition? A. Increased calcium intake with 3 glasses if non-fat milk daily. B. Reports a history of chronic urinary tract infections. C. Trains for competition and runs 12 miles every day. D. Received an implanted intrauterine device (IUD) last month. - CORRECT ANSWER Correct answer is D. When using IUD, the hormones act locally on the uterus—versus hanging out in your bloodstream, like with the pill—they also thin the uterine lining. In some women, the uterine lining is so thinned by the IUD that nothing comes out, aka no period." "A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record? A. Circulation impaired. B. Inflammation present. C. Reports feeling "on fire." D. Paresthesia reported. - CORRECT ANSWER Correct answer D." "The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture what should the nurse do first? A. Identify S1 and S2 heart sounds. B. Change to the bell of the stethoscope. C. Move the stethoscope to the apical site. D. Listen for abnormal sounds - CORRECT ANSWER Correct answer is A. 1st assessment of hearts sounds is to identify S1 and S2 heart sounds. S1 is normally a single sound because mitral and tricupsid valve closure occurs almost simultaneously. Clinically S1 corresponds to the pulse. The second sound S2 represents closure of the smilunar (aortic and pulmonary) valves." "During assessment of a client's neck, the nurse prepares to assess for jugular vein distention (JVD) as seen in the picture. What should the nurse do next? A. Listen to swishing sound during systole. B. Use the bell of the stethoscope to auscultate. C. Remove the stethoscope to observe the site. D. Palpate the site of erythema and tenderness. - CORRECT ANSWER Correct answer is C." "A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information? A. Conduct a comprehensive review of systems. B. Perform a head-to-toe physical assessment. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Collect information about the client's activities since surgery. - CORRECT ANSWER D. Collect information about the client's activities since surgery." "*A client presents with "cough." Which question by the nurse is likely to elicit the most information regarding a client's use of medications? A. What medications are you currently taking? B. Have you tried any generic brands of cough syrup? C. Have you been prescribed any medications for your cough? D. What medications have you used for your cough? - CORRECT ANSWER A. What medications are you currently taking?" "*A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? *A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer" - CORRECT ANSWER B. Describe having a "body-wracking dry cough" of 6 weeks duration." "*A patient reports smoking 1 pack of cigarettes per day for 30 years. The nurse reports this as: a.15 pack years b.30 pack years c.365 pack years d.10,950 pack years - CORRECT ANSWER B. 30 pack years multiple # PPD x number years smoked" "A patient comes to the emergency department and tells the triage nurse that he is "having a heart attack." What is the nurse's top priority at this time? A. Determine the patient's personal data and insurance coverage. B. Ask the patient to take a seat in the waiting room until his name is called. C. Request that a nurse collect data for a comprehensive history. D. Ask a nurse to start a focused assessment of this patient now. - CORRECT ANSWER D. Ask a nurse to start a focused assessment of this patient now." "Leading questions may initiate untrue or inaccurate responses because such questions: A.Encourage short or vague answers B.Require an educational level the patient may not possess C.Prompt the patient to try to give a particular answer D.Confuse the patient - CORRECT ANSWER C.Prompt the patient to try to give a particular answer" "Which is an example of data a nurse collects during a physical examination? A. The patient's lack of hair and shiny skin over both shins B. The patient's stated concern about lack of money for prescriptions C. The patient's complaints of tingling sensations in the feet D. The patient's mother's statements that the patient is very nervous lately - CORRECT ANSWER A. The patient's lack of hair and shiny skin over both shins" "What is the most important nursing action to reduce transmission of microorganisms during a physical assessment? a) Clean the bell and diaphragm of the stethoscope between patients. b) Perform hand hygiene. c) Wear gloves when anticipating exposure to body fluids. d) Wear eye protection when anticipating spatter of body fluids. - CORRECT ANSWER b) Perform hand hygiene." "Based on the picture, what is an appropriate nursing diagnosis for this client? a.Infection b.Fluid Volume Deficit c.Decreased Cardiac Output d.Acute Pain - CORRECT ANSWER b.Fluid Volume Deficit" "A nurse assessing a patient with liver disease expects to find which manifestation during the examination? a) Yellowish color in the axilla and groin b) Yellow pigmentation in the sclera c) Very pale skin on the palms d) Ashen-gray color in the oral mucous membranes - CORRECT ANSWER b) Yellow pigmentation in the sclera" "When performing a skin assessment of an adult patient, the nurse expects what finding? a) Reddened area does not blanch when gentle pressure is applied b) Indentation of the finger remains in the skin after palpation c) Flaking or scaling of the skin d)Return of skin to its original position when pinched - CORRECT ANSWER d)Return of skin to its original position when pinched" "A 45-year-old woman tells the nurse she is distressed by the presence of dark, coarse hair on her face that has recently developed. What is the nurse's most appropriate response to this patient? a) "This is simple vellus hair and it will decrease in amount over time." b) "Some women in your cultural group normally have dark hair on their faces." c) "This is unusual; female hair distribution should be limited to arms, legs, and pubis." d) "Coarse dark hair could result from hormonal changes such as from menopause." - CORRECT ANSWER d) "Coarse dark hair could result from hormonal changes such as from menopause."" "What type of scale is used to measure pressure ulcers? - CORRECT ANSWER *The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury. *19-23 = no risk *15-18 = mild risk *13-14 = moderate risk *less than 9 = severe risk" "What is used to assess eyes? - CORRECT ANSWER Snellen Chart" "* A client with streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect? A. Foreign body obstruction. B. Laryngeal polyps. C. Peritonsillar abscess. D. Nasal polyps - CORRECT ANSWER C. Peritonsillar abscess." "Which findings does the nurse expect when assessing the mouth of a healthy adult? Select all that apply. a.Lips appear pink, smooth, moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable e.Mucous membranes are dry and intact - CORRECT ANSWER a.Lips appear pink, smooth, moist, and symmetric b.Teeth are white, yellow, or gray, with smooth edges c.Slight roughness on the dorsum of the tongue d.Hard palate appears smooth, pale, and immovable" "During the history, a 65-year-old male patient reports smoking two packs of cigarettes a day for more than 40 years. With this knowledge, what should the nurse look for during the examination of this patient's mouth? a) Cracks and erythema in the corners of the mouth b) Slightly rough papillae on the dorsal surface of the tongue c) Smooth or beefy, red-colored, edematous tongue d) Painless, non-healing mouth ulcers - CORRECT ANSWER d) Painless, non-healing mouth ulcers" "When inspecting a patient's posterior wall of the pharynx and tonsils, a nurse documents which finding as abnormal? a) Both tonsils have a smooth surface. b) Left and right tonsils meet at the midline. c) Left and right tonsils extend beyond the posterior pillars. d) Both tonsils have a glistening appearance. - CORRECT ANSWER b) Left and right tonsils meet at the midline." "During a symptom analysis, a patient describes his productive cough and states his sputum is thick and yellow. Based on these data, the nurse suspects which factor as the cause of these symptoms? a) Virus b) Allergy c) Fungus d) Bacteria - CORRECT ANSWER d) Bacteria" "Which of the following characteristics are true regarding changes in the respiratory system of an older adult? a.Costal cartilages become calcified b.Thoracic expansion is increased c.Increase in the number of alveoli d.Increased residual volume e.Decreased vital capacity - CORRECT ANSWER a.Costal cartilages become calcified d.Increased residual volume e.Decreased vital capacity *Rationale: The costal cartilages become more calcified à the thorax is less mobile. The lungs are more rigid. Alveoli close off, which causes a decreased vital capacity (the max amount of air a person can expel from lungs) and an increased residual volume (amount of air remaining in lungs after a forceful expiration)" "A nurse informs a patient that her blood pressure is 128/78. The patient asks what the number 128 means. What is the nurse's appropriate response? "The 128 represents the pressure in your blood vessels when: a) "The ventricles relax and the aortic and pulmonic valves open." b) "The ventricles contract and the mitral and tricuspid valves close." c) "The ventricles contract and the mitral and tricuspid valves open." d) "The ventricles relax and the aortic and pulmonic valves close." - CORRECT ANSWER b) "The ventricles contract and the mitral and tricuspid valves close." "A nurse is completing a symptom analysis with a patient complaining of chest pain. When asked what makes the chest pain worse, the patient reports that coughing and sneezing increase the chest pain. Based on these data, what does the nurse suspect as the cause of this patient's chest pain? a) Stable angina b) Esophageal reflux disease c) Mitral valve prolapse d) Costochondritis - CORRECT ANSWER d) Costochondritis" "When auscultating the heart of a patient with pericarditis, the nurse expects to hear which sound? a) A systolic murmur b) An S3 heart sound c) A friction rub d) An S4 heart sound - CORRECT ANSWER c) A friction rub" "While taking a history, a nurse learns that this patient experiences shortness of breath (dyspnea). If the cause of the dyspnea is a cardiovascular problem, the nurse expects which abnormal finding on examination? a) Flat jugular neck veins b) Red, shiny skin on the legs c) Absent peripheral pulses d) Edema of the feet and ankles - CORRECT ANSWER d) Edema of the feet and ankles" "A nurse is assessing a patient's peripheral circulation. Which finding indicates venous insufficiency of this patient's legs? a) Paresthesias and weak, thin peripheral pulses b) Leg pain that is worsened by walking c) Edema that is worse at the end of the day d) Leg pain that decreases when the legs are lowered - CORRECT ANSWER c) Edema that is worse at the end of the day" "*While assessing the legs of a female client, the nurse observes leathery-looking skin. The client reports aching tired legs that swell if she stands for long periods of time. To screen for venous insufficiency, the nurse should ask the client if she has experienced which subject finding? A. Decreased pain when legs are elevated. B. Deep, continuous pain in the calf muscles. C. Cool, pale skin below the knees. D. Painful symptoms alleviated by warmth. - CORRECT ANSWER A. Decreased pain when legs are elevated." "*The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? (Select all that apply) A. Osteopenia. B. Kyphosis. C. Atrophy. D. Contracture. E. Crepitus - CORRECT ANSWER B. Kyphosis. C. Atrophy. D. Contracture." "As a patient is walking down the hall, the nurse notices the patient's staggering, unsteady gait and suspects a cerebellar problem. What findings does the nurse anticipate on the neurologic examination? a) When the patient stands with feet together, eyes open and then closed, an upright posture is maintained. b) When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers. c) When the patient is giving a history to the nurse, a tremor is noticed as the patient's hands rest in the lap. d) When lying supine, the patient is able to move the heel of one foot down the shin of the other leg. - CORRECT ANSWER b) When the patient touches the end of each finger to the thumb of the same hand, a tremor is observed in the fingers." "*The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen? * A. Pain notes when palpating McBurney's point. B. Nontender mass palpable in the RUQ. C. Rebound tenderness with compression over right lower quadrant. D. Firm mass palpated at bottom of left rib cage. - CORRECT ANSWER D. Firm mass palpated at bottom of left rib cage." "The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? a) Auscultation of fluid movement within the abdominal cavity b) Palpation of rebound tenderness c) Palpation of pitting edema of the abdomen d) Percussion of dullness over dependent areas of the abdomen - CORRECT ANSWER d) Percussion of dullness over dependent areas of the abdomen" "*The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. What action should the nurse implement? *A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client's bladder. C. Instruct the client in distraction and relation techniques. D. Notify the healthcare provider of the rebound tenderness. - CORRECT ANSWER D. Notify the healthcare provider of the rebound tenderness." "A patient tells the nurse, "I've been having gnawing pain in my upper belly for several weeks that is worse on an empty stomach." The nurse suspects: a)Gastroesophageal reflux disease b)Peptic ulcer disease c)Appendicitis d)Cholecystitis - CORRECT ANSWER b)Peptic ulcer disease" "*The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer? A. Measure the degree of join range of motion in the extremity. B. Compare the skin turgor of the client's upper and lower leg. C. Observe the specific location and appearance of the ulceration. D. Note any change in the color of the ulcer when the leg is moved - CORRECT ANSWER D. Note any change in the color of the ulcer when the leg is moved" "A patient reports having abdominal distention. The nurse observes that the patient's sclerae are yellow. Which abnormal finding does the nurse anticipate on examination of this patient's abdomen? a) Decreased bowel sounds in all quadrants b) Glistening or taut skin of the abdomen c) Bulge in the abdomen when coughing d) Bruit around the umbilicus - CORRECT ANSWER b) Glistening or taut skin of the abdomen" "What sound does a nurse expect to hear when using the bell of the stethoscope over the epigastric area of the abdomen of a healthy patient? a) Bowel sounds b) Venous hum c) Soft, low-pitched murmur d) No sounds - CORRECT ANSWER d) No sounds" "*The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal? A. Drenching night sweats. B. Excessive vaginal moisture. C. Increase in sexual desire. D. Cessation of menstruation. - CORRECT ANSWER A. Drenching night sweats." "*A client with a history of HIV comes to the outpatient clinic complaining of cough and chest pain with breathing. The nurse should first: a.Inspect for chest expansion and accessory muscle use. b.Retrieve a sputum sample to evaluate for hemoptysis c.Obtain data relating to a History of Present Illness d.Check CD4 count - CORRECT ANSWER c.Obtain data relating to a History of Present Illness" "the home care nurse is visting an older client whose spouse died six months ago. which behaviors by the client indicate effective coping? SATA a. looking at old photographs of family b. participating in a senior citizens program c. neglecting personal grooming d. visiting the spouse's grave once a month e. decorating a wall with the spouses's pictures and awards received - CORRECT ANSWER a. looking at old photographs of family b. participating in a senior citizens program d. visiting the spouse's grave once a month e. decorating a wall with the spouses's pictures and awards received" "the nurse is assessing a client who has been admitted to the coronary care unit. the client seems to flucutate in the ability to focus during the day. on the basis of this assessment, which client problem would the nurse suspect? a. dementia as a result of isolation b. dementia as a result of substance intoxication c. acute confusion as a result of hopsital induced psychosis d. interruption in the family as a result of alcohol withdrawal - CORRECT ANSWER c. acute confusion as a result of hopsital induced psychosis" "the nurse preparing to admit a client with a diagnosis of OCD to the mental health unit would expect to note which behaviors in the client? a. sad and tearful b. suspicous and hostile c. frightened and delusional d. rigidness in thought and inflexibility - CORRECT ANSWER d. rigidness in thought and inflexibility" "the nurse is caring for a client diagnosed with alzheimer's disease who is demonstrating characteristics of agnosia. which client behavior supports the presence of this cognitive deficiency? a. the client has difficulty with balance when rising from the chair b. the client has lost the cognitive ability to fold their own clothes c. the client recognizes children but has difficulty calling them by name d. when asked to pick up the cup, the client consistently fails to identify the cup - CORRECT ANSWER d. when asked to pick up the cup, the client consistently fails to identify the cup apraxia- inability to perform familar skilled activites" "a client with a history of panic disorder comes to the ED and states to the nurse "please help me. i think i am having a heart attack" what is the priority nursing action? a. assess the client's vital signs b. identify the clients acitivity during the pain c. assess for signs related to a panic disorder d. determine the client's use of relaxation techniques - CORRECT ANSWER a. assess the client's vital signs" "the nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. the nurse would assign priority to which assessment finding? a. tearful, self-isolated b. affect bland, withdrawn c. fist clenched, pounding table, fearful d. temperature 98.4, respirations 18 breaths/min - CORRECT ANSWER c. fist clenched, pounding table, fearful" "which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of PTSD? a. "im always crying" b. "im afraid to go outside" c. "i keep reliving the abuse" d. " i keep washing my hands over and over" - CORRECT ANSWER c. "i keep reliving the abuse"" "A client is admitted to the hospital with a diagnosis of BPH, and a trasnurethral resection of the prostate is performed. four hours after surgery, the nruse takes the cleitns vital signs and empties the urinary drainage bag. which assessment finding indicates the need to notify the PHCP? a. red, bloody urine b. pain rated as 4/10 c. urine output of 150 ml higher than intake d. BP: 100/50mm Hg: Pulse 130 bpm - CORRECT ANSWER d. BP: 100/50mm Hg: Pulse 130 bpm sign of excessive blood loss" "the nurse is caring for a client with resolved intenstinal obstruction who has a NG tube in place. the PCP has now prescribed that the NG tube be removed. what is the priority nursing assessment prior to removing the tube? a. checking for normal serum electrolyte levels b. checking for normal pH of the gastric aspirate c. checking for proper NG tube placement d. checking for proper NG tube placement - CORRECT ANSWER d. checking for proper NG tube placement" "a client with severe coronary artery disease who had cardiac surgeyr 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. the client received a single blous of 500 mL of IV fluid. urine output for the subsequent hour was 25 mL. daily lab results indicate that the BUN level is 45 mg/dL and the serum creatnine level is 2.2 mg/dL. on the basis of these findings, the nurse would anticipate that the client is at risk for which problem? a. hypovolemia b. acute kidney injury c. glomerulonephritis d. heart failure - CORRECT ANSWER b. acute kidney injury BUN levels 10-20 normal" "the nurse in postanesthia care unit is monitoring a client for signs of bleeding after a rhinoplasty. which observation indicates to the nurse that bleeding may be occuring? a. frequent swallowing b. client complaints of discomfort c. ecchymosis around the client's eyes d. blood on the external nasal dressing - CORRECT ANSWER a. frequent swallowing" "the nurse is conducting health screening for osteoporosis. which client is at greatest risk of developing this disorder? a. a 25 year old woman who runs b. a 36 year old man who has asthma c. a 70 year old man who consumes excess alcohol d. a sedentary 65 year old woman who smokes ciagarettes - CORRECT ANSWER d. a sedentary 65 year old woman who smokes ciagarettes" "the nurse is caring for a client after the application of a plaster cast for a fractured left radius, the nurse would suspect umpairment with the neurovascular status of the client casted extremity if which findings are noted? SATA a. capillary refill less than 3 seconds b. pulses present and with swollen, pink fingers c. client report of severe, deep, unrelenting pain d. client report of pain as nurse assess finger movement e. client report of numbness and tingling sensation in the fingers - CORRECT ANSWER c. client report of severe, deep, unrelenting pain d. client report of pain as nurse assess finger movement e. client report of numbness and tingling sensation in the fingers" "the clinic nurse is performing an assessment on a client with a diagnosis of RA: the nurse checks for which assessment finding that is associated with RA? a. age of onset is generally 65 years of age or older b. complaint of pain that is more severe after activity c. system symptoms such as fatigue,a norexia, and weight loss d. joint pain as assymetrical and associated with past injuries to the joint - CORRECT ANSWER c. system symptoms such as fatigue,a norexia, and weight loss" “A 29 year old male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body-wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter? A. Presents with a hacking non-productive cough of 6 weeks duration. B. Describe having a "body-wracking dry cough" of 6 weeks duration. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. D. Young adult male presents with fears that he has "lung cancer" - CORRECT ANSWER Correct answer is B, as assessment process inclu