VNSG 1423 Exam #2 Questions With
Complete Answers
Reminder devices that are used to help prevent falls include: - ANSWER bolsters
and over bed table Ch 13 pg 208 & 209
The minimum data set (MDS) is used to: - ANSWER collect essential information
Ch 5 pg 93-94
Which of the following assessment findings requires immediate intervention? -
ANSWER Non blanchable erythema of both heels Ch 21 pg 408- 409 Box 21.5
A nurse is conducting a neurological assessment on a client. The client was
unable to remember the date and time, how would the nurse document the level
of consciousness? - ANSWER AAOx3 to person, place and situation Ch 21 pg
397
When assessing the eyes of a client, which characteristic is commonly seen? -
ANSWER Shinning a light in opposite eye both pupils will constrict Ch 21 pg. 398
The nurse is attempting to locate the pedal pulse on a client who has been
admitted following injury to the upper right leg. The nurse should palpate and
document the location of the pulse as: - ANSWER On the dorsal surface of the
foot Ch 17 & 21, pg 320 & 411
A nursing assistant reports that a resident has been found lying on the floor of
the bathroom. Prioritize the actions of the nurse from first priority (1) to last
priority (4). - ANSWER ask if the patient is okay
assess vital signs
notify the supervisor
notify the physician
An appropriate intervention for a older, frail client who is at risk for falls is: -
ANSWER A 2 hours toileting schedule while the client is awake Ch 13, pg 207
Adequate circulation is present if the nail beds: - ANSWER blanch on pressure
and color returns in 5 seconds Ch 21, pg 410
, A nurse is assessing a client's thyroid gland as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? Select all
that apply. (3/5) - ANSWER feeling the thyroid ascend as the client swallows
inspection of the jugular veins for distention
palpating the thyroid in the lower half of the neck
hearing a bruit when auscultating the thyroid
visualizing the thyroid on inspection of the neck
pg 400
Which of the following findings should the nurse expect to hear when
auscultating the thorax (chest)? - ANSWER bronchovesicular ch 21, pg 402
a nurse is preparing to auscultating a client's abdomen as part of a
comprehensive physical examination. Which of the following findings should the
nurse expect? - ANSWER high pitched clicks ch 21, pg 407
A nurse is assessing a client during a comprehensive physical examination, the
nurse asses the head and neck. Which finding would the nurse expect in an
older adult? - ANSWER arcus senilis Ch 21, pg 398
A nurse observes smoke coming from under the door of the nurse's lounge.
Which of the following is the priority action by the nurse? - ANSWER evacuate
the clients Ch 13, pg 213
A nurse is caring for a client who was just admitted to the unit after falling at a
nursing home. The client is oriented to person, place, time and situation. Which
of the following actions by the nurse are appropriate to decrease the risk of a
fall? Select all that apply. (3/6) - ANSWER Provide the client with nonskid
footwear
Ensure that the client's call light is within reach
Complete a fall-risk assessment
Ch 13, pg 210
The nurse is performing a focused assessment of the client's cardiovascular
system every 4 hours. Which SPECIFIC assessment will the nurse include?
Select all that apply. - ANSWER capillary refill of extremities
strength and equality of peripheral pulses
skin, color, moisture and temperature
blood pressure
CH 21 pg 394
a nurse is maintaining a problem oriented medical record for a client. Which
component of the record describes the client's responses to what has been
done and revisions to the initial plan? - ANSWER progress note ch 5, pg 83
Complete Answers
Reminder devices that are used to help prevent falls include: - ANSWER bolsters
and over bed table Ch 13 pg 208 & 209
The minimum data set (MDS) is used to: - ANSWER collect essential information
Ch 5 pg 93-94
Which of the following assessment findings requires immediate intervention? -
ANSWER Non blanchable erythema of both heels Ch 21 pg 408- 409 Box 21.5
A nurse is conducting a neurological assessment on a client. The client was
unable to remember the date and time, how would the nurse document the level
of consciousness? - ANSWER AAOx3 to person, place and situation Ch 21 pg
397
When assessing the eyes of a client, which characteristic is commonly seen? -
ANSWER Shinning a light in opposite eye both pupils will constrict Ch 21 pg. 398
The nurse is attempting to locate the pedal pulse on a client who has been
admitted following injury to the upper right leg. The nurse should palpate and
document the location of the pulse as: - ANSWER On the dorsal surface of the
foot Ch 17 & 21, pg 320 & 411
A nursing assistant reports that a resident has been found lying on the floor of
the bathroom. Prioritize the actions of the nurse from first priority (1) to last
priority (4). - ANSWER ask if the patient is okay
assess vital signs
notify the supervisor
notify the physician
An appropriate intervention for a older, frail client who is at risk for falls is: -
ANSWER A 2 hours toileting schedule while the client is awake Ch 13, pg 207
Adequate circulation is present if the nail beds: - ANSWER blanch on pressure
and color returns in 5 seconds Ch 21, pg 410
, A nurse is assessing a client's thyroid gland as part of a comprehensive physical
examination. Which of the following findings should the nurse expect? Select all
that apply. (3/5) - ANSWER feeling the thyroid ascend as the client swallows
inspection of the jugular veins for distention
palpating the thyroid in the lower half of the neck
hearing a bruit when auscultating the thyroid
visualizing the thyroid on inspection of the neck
pg 400
Which of the following findings should the nurse expect to hear when
auscultating the thorax (chest)? - ANSWER bronchovesicular ch 21, pg 402
a nurse is preparing to auscultating a client's abdomen as part of a
comprehensive physical examination. Which of the following findings should the
nurse expect? - ANSWER high pitched clicks ch 21, pg 407
A nurse is assessing a client during a comprehensive physical examination, the
nurse asses the head and neck. Which finding would the nurse expect in an
older adult? - ANSWER arcus senilis Ch 21, pg 398
A nurse observes smoke coming from under the door of the nurse's lounge.
Which of the following is the priority action by the nurse? - ANSWER evacuate
the clients Ch 13, pg 213
A nurse is caring for a client who was just admitted to the unit after falling at a
nursing home. The client is oriented to person, place, time and situation. Which
of the following actions by the nurse are appropriate to decrease the risk of a
fall? Select all that apply. (3/6) - ANSWER Provide the client with nonskid
footwear
Ensure that the client's call light is within reach
Complete a fall-risk assessment
Ch 13, pg 210
The nurse is performing a focused assessment of the client's cardiovascular
system every 4 hours. Which SPECIFIC assessment will the nurse include?
Select all that apply. - ANSWER capillary refill of extremities
strength and equality of peripheral pulses
skin, color, moisture and temperature
blood pressure
CH 21 pg 394
a nurse is maintaining a problem oriented medical record for a client. Which
component of the record describes the client's responses to what has been
done and revisions to the initial plan? - ANSWER progress note ch 5, pg 83
