Solutions
A charge nurse is observing a newly licensed nurse perform an
anterior chest auscultation on a client. For which of the
following actions should the charge nurse intervene? Correct
Answers The nurse is auscultating through the client's gown
A charge nurse is reviewing the documentation of a newly
licensed nurse. Which of the following entries made by the
newly licensed nurse is an example of correct documentation?
Correct Answers inspiratory wheeze auscultated at left lateral
chest
A charge nurse is teaching a newly licensed nurse how to
recognize a pleural friction rub. Which of the following
descriptions should the nurse use to describe a pleural friction
rub? Correct Answers >coarse grating tone
>heard on inspiration and expiration
>pain with breathing
A charge nurse is teaching a newly licensed nurse how to
recognize manifestations of decreased oxygenation in a client.
Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching? Correct Answers
clubbing of the fingers indicates a chronic state of impaired
perfusion
A nurse assesses a client's respiratory rate and notes that it is
below the expected reference range. The nurse should identify
,that which of the following findings can decrease a client's
respiratory rate?
A. The client has been a chronic smoker for 10 years.
B. The client takes a narcotic pain medication for chronic pain.
C. The client reports anxiety due to being in the hospital.
D. The client has a history of anemia. Correct Answers B
A nurse has collected biographic data from a client. Which of
the following findings in the client's community is considered a
social determinant of health that can negatively impact the
client's health? Correct Answers Limited access to a pharmacy
A nurse has completed a cardiovascular assessment on a client.
Which of the following findings should the nurse report to the
provider? Correct Answers Capillary refill of 3 seconds
A nurse has received change-of-shift report. Which of the
following clients should the nurse assess first? Correct Answers
A client who has nausea and diaphoresis
A nurse in the emergency department is assessing a client who
has experienced thoracic trauma from a motor vehicle crash.
Which of the following findings is an indication of a
pneumothorax? Correct Answers the client is experiencing
unequal movement of the posterior chest
A nurse is admitting a client who has a new diagnosis of COPD.
Which of the following information documented by the nurse is
subjective data? Correct Answers >report from client says they
sleep while propped on two pillows at night
,>client says they quit smoking 2 years ago
> client states: being short of breath all of the time is making me
depressed
A nurse is admitting a client who has had a stroke. Which of the
following actions should the nurse take? Correct Answers Keep
client's bed in the lowest position
A nurse is admitting a client who is 162.6 cm (64 in) tall and
weighs 68.2 kg (150 lb). Using the BMI table shown below,
what should the nurse record as the client's BMI? Correct
Answers BMI = 25
A nurse is assessing a client who has a lump on their neck.
Which of the following questions should the nurse ask the
client? Correct Answers "Are you experiencing difficulty
breathing?"
"How long has the lump been on your neck?"
"Is the lump causing you discomfort?"
"Are you having difficulty swallowing?"
A nurse is assessing a client who reports an increase in their
stress level related to the demands of their job.
Which of the following interventions should the nurse
recommend for the client to reduce their stress? Correct
Answers Discuss the benefits of meditation with the client
A nurse is assessing a client with a dark skin tone. In which of
the following areas of the client's body should the nurse assess
the client for adequate oxygenation? Correct Answers Nail beds
Oral mucosa
, A nurse is assessing a client's head. Which of the following
should the nurse identify as an unexpected finding? Correct
Answers Oval white patches in the client's hair is correct. The
nurse should identify that oval white patches in the client's hair
can indicate head lice, or Pediculus humanus capitus.
A lesion on the client's scalp is correct. The nurse should
identify that a lesion on the client's scalp can indicate a skin
disorder or infection.
Protrusion of the client's head is correct. The nurse should
identify that protrusion of the client's head can indicate recent
trauma to the head.
Edema around the client's eyes is correct. The nurse should
identify that edema around the client's eyes, cheeks, or face can
indicate infection, trauma, or a heart disorder.
A nurse is assessing a client's jugular veins and carotid arteries.
The nurse should assist the client into which of the following
positions? Correct Answers Have the client lay supine with the
head of the bed at a 30° angle.
A nurse is assessing a client's mouth. The nurse should identify
that which of the following is an expected finding? Correct
Answers Large vein on the ventral surface of the tongue
A nurse is assessing a client's respirations and notes they are
shallow and at a rate of 24/min. The nurse should identify this as
which of the following unexpected findings?