LPN 1001 Basic Physical Assessment Questions with Answers Graded A+

LPN 1001 Basic Physical Assessment All of the following components may be part of a client's medical record. When reviewing the client's chart, which will the nurse identify as the major source of subjective data about the client's health status? Correct response: • Health history A client presents to the emergency department with a closed head injury. What would the nurse ask the client to help assess cerebral function? Correct response: • "Have you noticed a change in your memory?" The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include? Correct response: • "At first, the stoma may bleed slightly when touched." A client complains of lower abdominal pressure. The nurse notes a firm mass extending above the symphysis pubis. Which condition is the most likely cause of these findings? Correct response: • Distended bladder The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct? Correct response: • "Checking both carotid arteries at the same time may impair cerebral circulation." A nurse is collecting data on an older adult client. Which finding should the nurse anticipate as part vitalof the normal degenerative changes associated with aging? Correct response: • diminished reflexes Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should: Correct response: • withhold food and fluids. The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective? Correct response: • Yogurt and kale The nurse-manager asks a newly hired LPN if the facility’s rules of ethical conduct are understood. Which statement by the LPN indicates the need for further education? Correct response: • "I don't discuss advance directives unless the client initiates the conversation." The nurse is teaching a client about the safe use of an I.V. infusion pump that he'll require at home after discharge. Which statement by the client indicates the need for further teaching? Correct response: • "If it shocks me, I'll wait 10 minutes before using it again." A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take? Correct response: • Contact the home health agency and provide a report of the client's condition and needs. A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. Which task should she assign to another LPN? Correct response: • Performing dressing changes The nurse-manager has posted shift assignments on the unit. Which duty should the licensed practical nurse (LPN) refuse? Correct response: • Conducting the admission assessment on a new client A client comes to the clinic seeking medical attention for a rash. The nurse gathers information about the rash and finds that the client's back and right side are covered with vesicles. A vesicular rash may be associated with which conditions? Select all that apply. Correct response: • contact dermatitis • herpes zoster • smallpox The nurse is caring for a preschool aged child who has been prescribed a preoperative intramuscular (IM) injection at 07:00. To elicit the child’s cooperation in administering this medication, the nurse should use which approach? Correct response: • Let the preschooler choose which leg to use for the injection. A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require? Correct response: • A chest X-ray A nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a patient-controlled analgesia pump. Which finding indicates that the client is obtaining adequate pain relief? Correct response: • Pain rating of 2 or 3 on a scale of 0 to 10 A client who was brought to the emergency department after a motor vehicle crash is reporting abdominal pain. Which finding would the nurse report prior to the health care provider performing peritoneal lavage? Correct response: • Distended bladder A client performs monthly self-breast examinations. Which finding should the client promptly report? Correct response: • A hard, nontender mass in the upper outer quadrant of the left breast When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education? Correct response: • slowed reaction time An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection? Correct response: • Allowing extra time for this task The nurse mentor is observing a newly hired nurse while she performs a head-to-toe assessment. The mentor knows the newly hired nurse is effective in evaluating a client's posterior tibial pulse when she palpates which area? Correct response: • On the inner aspect of the ankle, below the medial malleolus The nurse educator is explaining to a group of newly hired nurses how to auscultate a client's chest. What information would the nurse educator include to explain how to differentiate a pleural friction rub from other abnormal breath sounds? Correct response: • A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. A client has just undergone a bronchoscopy. Which priority nursing intervention will the nurse perform at this time? Correct response: • checking airway patency A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next? Correct response: • Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth. The nursing instructor asks the nursing student to describe the anatomic position. How would the student correctly respond? Correct response: • "The client's palms are turned forward." The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation? Correct response: • "S1 is loudest at the apex, and S2 is loudest at the base." A nurse must evaluate a client's splinted extremity for neurovascular damage. What is the priority action by the nurse? Correct response: • Compare color and capillary refill of both extremities. The physician orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions? Correct response: • Place an isolation cart containing gloves and gowns outside the client's room. A client has been admitted to the hospital with signs of dehydration. Which action would be least beneficial in increasing the client's fluid intake? Correct response: • Serving fluids in large amounts Which trait is the most important for ensuring that a nurse-manager is effective? Correct response: • Communication skills The physician states that he'll refer his client to a home health agency after discharge from the hospital. When is the most appropriate time for a referral to be initiated for a hospitalized client? Correct response: • As soon as the need is identified The nurse-manager asks the staff to decrease costs on the unit. Which practice would be the most beneficial in reducing costs? Correct response: • Taking only necessary supplies into the clients' rooms The nurse is obtaining a client's pulse rate. Which pulse features should the nurse document? Select all that apply. Correct response: • rhythm • amplitude The nurse is collecting data from a postoperative client. The nurse documents which subjective data? Select all that apply. Correct response: • client's description of pain • client's nausea A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform? Correct response: • Check the glucose level. A primipara client at 32 weeks' gestation comes to the hospital reporting vaginal bleeding. She has soaked one peri-pad and has no pain or cramps. Based on this data, the nurse would most likely suspect which condition? Correct response: • placenta previa A nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When evaluating the client's pulse rate, what should the nurse remember? Correct response: • Count the apical or radial pulse for 60 seconds. A nurse is caring for a client with myasthenia gravis. Which behavior during dinner indicates to the nurse that the client is having a therapeutic response to pyridostigmine?. Correct response: • The client swallows food without difficulty. The nurse is obtaining vital signs for several clients. Which client's vital signs would be the priority to report to the health care provider? Correct response: • postoperative client with a pulse of 110 beats/minute on awakening in the morning The nurse plans to obtain client information from a primary source. Which does the nurse identify as a primary information source and collects data from? Correct response: • The client A client reports abdominal pain. Which question, if asked by the nurse, would best elicit as much information about the pain as possible? Correct response: • "What does the pain feel like?" To evaluate a client's chief concern, the nurse practitioner (NP) performs deep palpation. The nurse recognizes the purpose of deep palpation is to assess which of the following? Correct response: • Organs A nurse is performing a head-to-toe assessment. Which part of the hand should the nurse use to evaluate this client's body for warmth? Correct response: • Dorsal surface The health care team is performing cardiac compressions on an adult client. To assess the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR), the nurse palpates which pulse site on this client? Correct response: • Carotid An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client? Correct response: • Carotid A nurse is discussing skin turgor evaluation of an elderly client with her peers. While doing so, the nurse should include which information with her colleagues? Correct response: • Inelastic skin turgor is a normal part of aging. An elderly client is scheduled for discharge from the hospital. Which statement by the client indicates that further teaching is needed? Correct response: • "My daughter just recently waxed my hardwood floors." The nurse is preparing a client for surgery that's scheduled in 1 hour. During preparation, the client states that he doesn't understand the surgical procedure and wishes not to proceed with surgery. What action should the nurse take? Correct response: • Ask the surgeon to speak with the client about his concerns before surgery. The nurse is caring for a client who had a bronchoscopy performed 60 minutes ago. The client reports being thirsty and requests a drink of water. What is the priority intervention by the nurse? Correct response: • Assess the gag reflex. A client is at risk for the development of hypovolemic shock after a prostatectomy. Which vital sign indicates that the client may be developing postoperative shock? Correct response: • BP 86/50, heart rate 102 The unlicensed assistive personnel (UAP) reports to the nurse that a client became short of breath while being bathed but is breathing better now. Which action should the nurse take first? Correct response: • Check the client and gather subjective and objective data related to shortness of breath. While assisting a health care provider perform a musculoskeletal assessment on a client, the nurse asks the client to perform supination. Which graphic depicts a joint in supination? Correct response: • A licensed practical nurse (LPN) who typically works on a medical-surgical unit is being cross- trained to work with postpartum clients. The nurse-manager is busy with a client who is giving birth and assigns the LPN to stock client rooms. Entering a client's room, the LPN notices that the client looks pale and shaky. Which action should the LPN take? Correct response: • Check the client's vital signs and fundus comparing to baseline data, and then notify the nurse-manager. A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client? Correct response: • Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin The vital signs of a client are temperature, 98.6 F (37 C) orally; pulse, 80 beats/minute; and respirations, 30 breaths/minute. Which interpretation of these values is correct? Correct response: • Respirations are above the normal range. The nurse is obtaining data regarding a client’s deep tendon reflexes. Which graphic shows the nurse assessing the biceps reflex? Correct response: • A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? Correct response: • Obtain vital signs. A nurse reinforces home care instructions to a client who is being seen in the clinic for bacterial conjunctivitis of the right eye. Which client statement indicates an understanding of the instructions? Correct response: • “I should use good hand washing to help to reduce the spread of this infection to others.” The nurse educator is presenting an in-service on collecting data on the geriatric client and asks the nursing staff which aging-related physiologic changes happens to the elderly client. The educator determines the staff have a good understanding of changes in the geriatric population when they identify which changes? Select all that apply. Correct response: • increased coronary artery blood flow • delayed gastric emptying The nurse is palpating the client’s arterial pulses. Which graphic displays the appropriate site for palpating the dorsalis pedis pulse? Correct response: • While collecting data on a newly admitted client, the nurse notes clear, thin nasal discharge. This type of nasal discharge may indicate: Correct response: • cerebrospinal fluid leak. All of the following components may be part of a client's medical record. When reviewing the client's chart, which will the nurse identify as the major source of subjective data about the client's health status?