Exit HESI Test Bank (answered) spring 2022/2023

1. A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? A. Rely on the fact that their needs will be met B. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality C. Must have needs ignored for short periods to develop a healthy personality D. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs - A. Rely on the fact that their needs will be met 2. A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. Which action should the nurse take? A. Tell the mother that the infant's weight is increasing as expected B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes D. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate - A. Tell the mother that the infant's weight is increasing as expected 3. A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suspect the presence of hydrocephalus B. Suggest to the pediatrician that a skull x-ray be performed C. Tell the mother that the infant is growing faster than expected D. Document these measurements in the infant's health-care record - D. Document these measurements in the infant's health-care record 4. A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "If you breastfeed, your infant is protected from infection." Exit HESI Test Bank (answered) spring 2022. C. "The transfer of your antibodies protects your infant until the infant is 12 months old." D. "The immune system of an infant is immature, and the infant is at risk for infection." - D. "The immune system of an infant is immature, and the infant is at risk for infection." 5. A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A. The infant babbles. B. The infant says "Mama." C. The infant smiles and coos. 6. D .The infant babbles single consonants. - B. The infant says "Mama." 7. The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast - D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast 8. A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Dip the infant's pacifier in maple syrup so that the infant will suck - A. Use water and a cotton swab and rub the teeth 9. A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "I can mix the food in the my infant's bottle if he won't eat it." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." 10.D "Meats are really important for iron, and I should start feeding meats to my infant right away." - C. "Egg white should not be given to my infant because of the risk for an allergy." 11.A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat B. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant C. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags D. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car - A. To secure the infant in the middle of the back seat in a rearfacing infant safety seat 12.A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "I need to keep large toys out of the crib." B. "The drop side needs to be impossible for my infant to release." C. "Wood surfaces on the crib need to be free of splinters and cracks." D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." - D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." 13.The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? A. Initiative versus guilt B. Trust versus mistrust C. Industry versus inferiority D. Autonomy versus doubt and shame - D. Autonomy versus doubt and shame 14.A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? A. Spend as much time as possible with the toddler B. Keep hospital routines as similar as possible to those at home C. Allow the toddler to play with other children in the nursing unit playroom D. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room - B. Keep hospital routines as similar as possible to those at home 15.A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? A. Blocks and push-pull toys B. Finger paints and card games C. Simple board games and puzzles D. Videos and cutting-and-pasting toys - A. Blocks and push-pull toys 16.A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? A. To separate her children during playtime B. That if the behavior continues, she will need to bring her children to a child psychologist C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity D. To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again - C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity 17.A nurse is assessing the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. A. Put on and tie his shoes B. Align two or more blocks C. Dress himself appropriately D. Go to the bathroom without help E. Turn the pages of a book one at a time - B. Align two or more blocks F. Turn the pages of a book one at a time 18.AA nurse is assessing language development in a toddler from a bilingual family. What should the nurse expect about the child's language development? A. Is slower than expected B. Is developing as expected C. Is more advanced than expected D. Will require assistance from a speech therapist - A. Is slower than expected Soon after the first primary tooth erupts, usually around 1 year of age 19.AA mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? A. At age 3 B. Just before beginning kindergarten C. Twelve months after the first primary tooth erupts D. Soon after the first primary tooth erupts, usually around 1 year of age - D. 20.The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? A. The child has been walking for 2 years. B. The child can eat using a fork and knife. C. The child no longer has temper tantrums. D. The child can remove his or her own clothing. - D. The child can remove his or her own clothing. 21.The mother of a 9 year old child who is 5 feet 1 inch in height asks a nurse about car safety seats. What should the nurse tell the mother to use? A. Front booster seat B. Rear convertible seat C. Forward-facing car seat D. Rear seat using lap and shoulder seat belts - D. Rear seat using lap and shoulder seat belts 22.The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? A. Once a year B. Every 3 months C. Every 6 months D. Whenever a new primary tooth erupts - C. Every 6 months 23.AA nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist is developing which psychosocial stage? A. Initiative B. Autonomy C.A sense of trust D. A sense of industry - D. A sense of industry 24.AA nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child? A. Mastering useful skills and tools B. Gaining independence from parents C. Developing a sense of trust in the world D. Developing a sense of control over self and body functions - A. Mastering useful skills and tools 25.AA school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? A. Brush their teeth every morning and at bedtime B. Brush and floss their teeth after meals and at bedtime C. Brush and floss their teeth every morning and at bedtime D. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime - B. Brush and floss their teeth after meals and at bedtime 26.The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? A. That this is normal behavior for an adolescent B. To restrict any social privileges until the behavior stops C. That this type of behavior is usually the result of parents' spoiling a child D. That their daughter will need to see a child psychologist if the behavior continues - A. That this is normal behavior for an adolescent 27.AA nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? A. Body image B. Obtaining adequate nutrition C. Keeping up with schoolwork D. Obtaining adequate rest and sleep - A. Body image 28.The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? A. Hepatitis B is a concern with body piercing B. Infection always occurs when body piercing is done C. Body piercing is generally harmless as long as it is performed under sterile conditions D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) - C. Body piercing is generally harmless as long as it is performed under sterile conditions 29.AA sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? A. Use of a latex condom can prevent transmission of STIs B. The only way to prevent transmission of STIs is abstinence C. Use of a latex condom is a good method for preventing pregnancy D. A spermicide needs to be used along with a condom to prevent transmission of STIs - A. Use of a latex condom can prevent transmission of STIs 30.AA nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? A. Young adults ignore their risk for a serious illness B. Young adults are unable to afford health insurance C. Young adults are exposed to hazardous substances D. Young adults ignore physical symptoms and postpone seeking health care - D. Young adults ignore physical symptoms and postpone seeking health care 31.AA nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. A. The young adult is sensitive to criticism. B. The young adult verbalizes unrealistic fears. C. The young adult verbalizes disappointment with life. D. The young adult verbalizes satisfaction with friendships. E. The young adult has a sense of meaning and direction in life. - D. The young adult verbalizes satisfaction with friendship. F. The young adult has a sense of meaning and direction in life. 32.According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? A. Redefining self-perception and capacity for intimacy B. Providing guidance during interactions with his children C. Verbalizing readiness to assume parental responsibilities D. Making decisions concerning career, marriage, and parenthood - B. Providing guidance during interactions with his children 33.AA nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? A. Encouraging the client to feed herself B. Ensuring that most of the diet consists of liquids C. Monitoring the client during meals to ensure that food is swallowed D. Consulting with the health care provider regarding feeding through an enteral tube - C. Monitoring the client during meals to ensure that food is swallowed 34.AA nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? A. Report the findings to the health care provider B. Document the findings in the medical record C. Ask the health care provider for a prescription for a nighttime sedative D. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours - B. Document the findings in the medical record 35.AA nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? A. Encouraging at least one daytime nap B. Discouraging the use of a night light at bedtime C. Encouraging bedtime reading or listening to music D. Discouraging social interaction, particularly at bedtime - C. Encouraging bedtime reading or listening to music 36.AA nurse is performing an admission assessment on an older client who will be seen by a health care provider in a health care clinic. When the nurse asksthe client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? A. Report the client's concern to the health care provider B. Ask the client about medications he is taking C. Document the client's concern in the medical record D. Tell the client that sexual dysfunction is a normal age-related change - B. Ask the client about medications he is taking 37.AA community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? A. It is best to do grocery shopping and other errands late in the day B. They must stay in the house and ask a neighbor or family member to run their errands C. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses - D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses 38.AA nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? A. The normal aging process increases the production of surfactant B. The normal aging process increases respiratory system compliance C. The normal aging process decreases an older client's ability to clear secretions D. The normal aging process decreases the number of alveoli and increases the function of those remaining - C. The normal aging process decreases an older client's ability to clear secretions 39.An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? A. "It is caused by hereditary factors." B. "A loss of melanin occurs in the normal aging process." C. "The skin on the scalp becomes thin, causing moisture to escape." D. "The number of sweat glands and blood vessels decreases in the normal aging process." - B. "A loss of melanin occurs in the normal aging process." 40.AA nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? A. "I should drink extra fluids during the summer." B. "I should wear cool, light clothing in warm weather." C. "I need to wear a hat with a wide brim when I go outdoors." D. "I need to wear additional antiperspirant and deodorant in warm weather." - D. "I need to wear additional antiperspirant and deodorant in warm weather." 41.AA nurse is reviewing the medical record of an older client with presbycusis. Which finding should the nurse expect to note in the client's record? A. Unilateral conductive hearing loss B. Difficulty hearing low-pitched tones C. Difficulty hearing whispered words in the voice test D. Improved hearing ability during conversational speech - C. Difficulty hearing whispered words in the voice test 42.AA nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age- related finding? A. Thin, ridged toenails B. Thick skin on the lower legs C. Bounding dorsalis pedis pulse D. Loss of hair on the lower legs - D. Loss of hair on the lower legs 43.AA nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? A. Document the findings B. Notify the health care provider immediately C. Obtain a prescription for a muscle relaxant D. Ask the health care provider about referring the client to a neurological specialist - A. Document the findings 44.AA nurse observes an unlicensed assistive personnel (UAP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the UAP performs which action? A. Uses short sentences B. Overarticulates words C. Uses facial expressions or gestures D. Speaks at a normal rate and volume - B. Overarticulates words 45.A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? 46.A.Spouse and spouse's parents 47.B. Foster children and their parents 48.C. Spouse's children from a previous marriage 49.D. Aunts, uncles, grandparents, and cousins - D. Aunts, uncles, grandparents, and cousins 50.AA home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? A. The client's son B. The client's father C. The client's mother D. The client's grandson - C. The client's mother 51.AA female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? A. It can be used along with a male condom B. That it is 100% safe in preventing pregnancy C. That it offers protection against sexually transmitted infections (STIs) D. That it does not have to be discarded after use and can be used several times before a new one must be obtained - C. That it offers protection against sexually transmitted infections (STIs) 52.AA nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? A. "I need to reapply spermicidal cream with repeated intercourse." B. "The diaphragm needs to be filled with spermicidal cream before insertion." C. "The diaphragm can be inserted as long as 6 hours before intercourse." D. "I can leave the diaphragm in place as long as I want after intercourse." - D. "I can leave the diaphragm in place as long as I want after intercourse." 53.AA nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? A. Personal preference B. Family planning goals C. Work and home schedules D. Desire to have children in the future - A. Personal preference 54.AA sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? A. Diaphragm B. Spermicide C. Sterilization D. Male condom - C. Sterilization 55.AA nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask? A. "Are you dieting?" B. "Do you smoke cigarettes?" C. "Do you engage in strenuous exercise such as jogging?" D. "Do you normally have menstrual cramps with your periods?" - B. "Do you smoke cigarettes?" 56.AA nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? A. The client has hyperlipidemia. B. The client has type 2 diabetes mellitus. C. The client is being treated for hypertension. D. The client has been treated for breast cancer. - D. The client has been treated for breast cancer. 57.Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? A. The couple should engage in coitus once a week during treatment B. The health care provider should be notified immediately if breast engorgement occurs C. If the oral tablets are not successful, the medication will be administered intravenously D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies - D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies 58.AA nurse is reviewing the medical notes of a client seen by the health care provider to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which finding is documented? A. Amenorrhea B. Palpable fetal movement C. Thinning of the cervix D. Positive result on home urine test for pregnancy - B. Palpable fetal movement 59.AA nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A. Fetoscope B. Stethoscope C. Doppler transducer D. Pulse oximetry on the client and a fetoscope - C. Doppler transducer 60.AA nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? A. Document the findings B. Notify the health care provider of the finding C. Wait 15 minutes and then recheck the FHR D. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time - A. Document the findings 61.AA nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? A. Chest of the fetus B. Back of the fetus C. Carotid artery in the neck of the fetus D. Brachial area of one extremity of the fetus - B. Back of the fetus 62.AA nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? A. Asks the mother to lie still while both the FHR and the radial pulse rate are counted. B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. C. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. D. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. - B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. 63.AA nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? A. A reassuring sign B. A nonreassuring sign C. An indication of fetal distress D. An indication of the need to contact the health care provider - A. A reassuring sign 64.AA nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating which? A. A thinning of the cervix B. A positive sign of pregnancy C. That cervical softening is present D. That the cervix was seen to be violet - D. That the cervix was seen to be violet 65.AA client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), what does the nurse determine? A. Gravida 6, para 2 B. Gravida 2, para 6 C. Gravida 2, para 2 D. Gravida 3, para 6 - A. Gravida 6, para 2 66.AA nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2015. When does the nurse determine the estimated date of delivery to be? A. July 6, 2016 B. May 6, 2016 C. June 6, 2016 D. May 30, 2016 - C. June 6, 2016 67.AA rubella titer is performed on a pregnant client, and the results indicate a titerof less than 1:8. What should the nurse tell the client? A. The test results are normal B. She has developed immunity to the rubella virus C. The test will need to be repeated during the pregnancy D. She must have been exposed to the rubella virus at some point in her life - C. The test will need to be repeated during the pregnancy 68.AA hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? A. The results are negative B. The client needs to receive the hepatitis B series of vaccines C. The results indicate that the mother does not have hepatitis B D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth - D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth 69.AA multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? A. 6 weeks B. 8 weeks C. 12 weeks D. 16 weeks - D. 16 weeks 70.The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? A. "I need to avoid eating fried or greasy foods." B. "I need to be sure to drink adequate fluids with my meals." C. "I should eat five or six small meals a day rather than three full meals." D. "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." - B. "I need to be sure to drink adequate fluids with my meals." 71.AA nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply. A. Sleep lying on her back B. Shower daily but avoid sitting in a bathtub C. Apply cool compresses to the hemorrhoids D. Contact the nurse-midwife if any bleeding occurs E. Elevate her hips on a pillow when resting or during sleep - C. Apply cool compresses to the hemorrhoids F. Elevate her hips on a pillow when resting or during sleep 72.AA pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? A. Complementary alternative therapies should not be used during pregnancy B. Devices that apply pressure alone are available over the counter C. The health care provider or nurse-midwife needs to provide a prescription for acupressure D. It is all right to try any type of complementary alternative therapy to relieve the nausea - B. Devices that apply pressure alone are available over the counter 73.AA nurse is telling a pregnant client about the signs that must be reported to the health care provider or nurse-midwife. The nurse tells the client that the health care provider or nurse-midwife should be contacted if which occurs? A. Morning sickness B. Breast tenderness 74.C.Urinary frequency 75.D. Puffiness of the face - D. Puffiness of the face 76.AA pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? A. "Don't be concerned; any 2-year-old would welcome a newborn." B. "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." C. "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." D. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." - D. "Even though a 2- year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." 77.AA Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? A. A female health care provider examines the woman B. The woman's husband remains in the examining room at all times C. The woman is examined without any other people in the examining room D. Written permission is obtained from the woman to obtain subjective health data - A. A female health care provider examines the woman 78.AA nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? A. Lettuce B. Oranges C. Broccoli D. Pinto beans - D. Pinto beans 79.AA pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? A. The procedure takes about 2 hours B. She will be positioned on her back for the procedure C. A probe coated with gel will be inserted into the vagina D. That she may need to drink fluids before the test and may not void until the test has been completed - D. That she may need to drink fluids before the test and may not void until the test has been completed 80.An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? A. Determination of fetal lung maturity B. Checking the amniotic fluid for intrauterine infection C. Checking the fetal cells for chromosomal abnormalities D. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid - A. Determination of fetal lung maturity 81.AA nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? A. Absence of accelerations after fetal movement B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds C. Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement D. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline - A. Absence of accelerations after fetal movement 82. A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Arrange the actions in the order that they should be performed. All options must be used. - The correct order is: 83.Assess the fetal heart rate 84.Assess the color, odor, and other characteristics of the amniotic fluid 85.Check the woman's heart rate and blood pressure 86.Assist the woman in cleaning the perineal area 87.Ask the woman about the need to void 88.AA nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? A. Recheck the vital signs in 1 hour B. Notify the nurse-midwife of the findings C. Continue collecting subjective and objective data D. Document the findings in the client's medical record - B. Notify the nursemidwife of the findings 89.AA nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? A. Document the findings. B. Check the client's temperature. C. Report the findings to the nurse-midwife. D. Obtain a sample of the amniotic fluid for laboratory analysis. - A. Document the findings. 90.AA client in labor complains of back discomfort. Which position will best aidin relieving the discomfort? A. Prone B. Supine C. Standing D. Hands and knees - D. Hands and knees 91.AA nurse monitoring a client in labor notes this fetal heart rate pattern (referto figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? A. Stop the oxytocin (Pitocin) infusion B. Notify the nurse-midwife or health care provider C. Administer oxygen with a face mask at 8 to 10 L/min D. Continue to monitor the client and fetal heart rate patterns - D. Continue to monitor the client and fetal heart rate patterns 92.AA nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately? A. Notify the nurse-midwife or health care provider B. Perform a vaginal examination on the mother C. Position the mother so that her hips are elevated D. Insert a gloved finger into the mother's vagina to feel for cord compression - C. Position the mother so that her hips are elevated 93.AA woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? A. Cleansing breaths B. Blowing repeatedly in short puffs C. Holding her breath and using the Valsalva maneuver D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction - B. Blowing repeatedly in short puffs 94.AA woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? A. Pruritus B. Vomiting C. Headache D. Hypertension - C. Headache 95.AA nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? A. Stopping the oxytocin infusion B. Notifying the nurse-midwife or health care provider C. Checking the woman's blood pressure and pulse D. Increasing the intravenous (IV) rate of the nonadditive solution - A. Stopping the oxytocin infusion 96.Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? A. In the pelvic cavity B. 2 cm above the umbilicus C. At the level of the umbilicus D. Midway between the symphysis pubis and umbilicus - D. Midway between the symphysis pubis and umbilicus 97.AA nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? A. Documenting the finding B. Helping the woman get out of bed and walk C. Performing active and passive range-of-motion exercises D. Reporting the finding to the nurse-midwife or health care provider immediately - A. Documenting the finding 98.AA nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow? A. Scant B. Light C. Moderate D. Heavy - C. Moderate 99.AA woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? A. Applying an ice pack to the perineum B. Contacting the nurse-midwife or health care provider C. Administering an intravenous (IV) opioid analgesic D. Assisting the woman in taking a warm sitz bath - A. Applying an ice pack to the perineum 100. A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? A. "My temperature needs to remain within a normal range." B. "Frequent urination and burning when I urinate are expected." C. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." D. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs." - B. "Frequent urination and burning when I urinate are expected." 101. A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take? A. Checking the client's uterine fundus B. Notifying the nurse-midwife immediately C. Documenting the vital signs in the client's medical record D. Continuing to check the client's vital signs every 15 minutes - A. Checking the client's uterine fundus 102. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? A. Recheck the score in 5 minutes B. Initiate cardiopulmonary resuscitation C. Provide no action except to support the infant's spontaneous efforts D. Gently stimulate the infant by rubbing his back while administering oxygen - D. Gently stimulate the infant by rubbing his back while administering oxygen 103. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take? A. Documenting the findings B. Contacting the pediatrician C. Placing the infant in an oxygen tent D. Wrapping an extra blanket around the infant - A. Documenting the findings 104. A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure? A. In the axillary area B. At the level of the nipples C. 2 inches below the nipples D. At the level of the umbilicus - B. At the level of the nipples 105. A nurse in the pediatrician's office is checking the Babinski reflex in a 3- month-old infant. The nurse determines that the infant's response is normal if which finding is noted? A. The infant turns to the side that is touched. B. The fingers curl tightly and the toes curl forward. C. The toes flare and the big toe is dorsiflexed. D. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. - C. The toes flare and the big toe is dorsiflexed. 106. Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? A. Gluteal muscle B. Deltoid muscle C. Rectus femoris muscle D. Vastus lateralis muscle - D. Vastus lateralis muscle 107. A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. Based on this result, which action should the nurse take first? A. Hold the next scheduled feeding B. Contact the nurse-midwife or health care provider C. Document the results in the newborn's medical record D. Ask the laboratory to draw another blood sample in 2 hours and repeat the test - B. Contact the nurse-midwife or health care provider 108. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action? A. Washes the diaper area first B. Washes the infant's chest first C. Uncovers only the body part being washed D. Uses a cotton-tipped swab to carefully clean inside the infant's nose - C. Uncovers only the body part being washed 109. The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? A. To bring the infant to the pediatrician's office to be checked B. That the crust is to be expected as a normal part of healing C. To remove the crust, using a warm, wet face cloth and a mild soap D. That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours - B. That the crust is to be expected as a normal part of healing 110. A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother? A. That this is normal for breastfed infants B. To decrease the number of feedings by two per day C. That the stools should be solid and pale yellow to light brown D. To monitor the infant for infection and, if a fever develops, to contact the pediatrician - A. That this is normal for breastfed infants 111. A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? A. Squeeze the infant's nail beds B. Squeeze the infant's brachial area C. Apply pressure with a finger over the umbilical area D. Apply pressure with a finger on the infant's forehead - D. Apply pressure with a finger on the infant's forehead 112. A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, which action should the nurse take? A. Check the infant for jaundice B. Check the infant's temperature C. Obtain parental consent to administer the vaccine D. Request that a hepatitis blood screen be performed on the infant - C. Obtain parental consent to administer the vaccine 113. A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. D. The client has diminished reflexes in the legs. - C. The client states that he has a rash. 114. A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch scar is present on the lower right portion of the abdomen. - D. A 1 × 2-inch scar is present on the lower right portion of the abdomen. 115. A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Follow-up C. Emergency D. Complete - D. Complete 116. A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to follow-up care B. A complete (total health) database C. Data related to the respiratory system D. Data related to the treatment for the cold - C. Data related to the respiratory system 117. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination B. Ask health history questions while performing the examination and initiating emergency measures C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room - B. Ask health history questions while performing the examination and initiating emergency measures 118. A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Follow-up C. Complete (total) D. Problem-centered - B. Follow-up 119. A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis B. Make accurate nursing diagnoses C. Identify any hereditary traits related to the epilepsy D. Determine what the client believes has caused the epilepsy - D. Determine what the client believes has caused the epilepsy 120. A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? A. The client has a fever B. The skin temperature is normal C. The client needs to drink additional fluids D. The client needs to have the blanket removed - B. The skin temperature is normal 121. A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? A. Xerosis B. Pruritus C. Seborrhea D. Actinic keratoses - A. Xerosis 122. A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? A. Darken the room B. Obtain informed consent from the client C. Obtain a scalpel and a slide for diagnostic evaluation D. Obtain medication to anesthetize the skin area before proceeding with the examination - A. Darken the room 123. A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? A. Anasarca B. Ecchymosis C. Unilateral edema D. Increased vascularity of the skin tissue - A. Anasarca 124. A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? A. 1+ edema B. 2+ edema C. 3+ edema D. 4+ edema - C. 3+ edema 125. A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by which? A. Contraction of the underlying blood vessels B. A reduced amount of bilirubin in the blood C. Diminished perfusion of the surrounding tissues D. Excess blood in the dilated superficial capillaries - D. Excess blood in the dilated superficial capillaries 126. A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. A. Ensuring that the room is private B. Seeing that distracting objects are removed from the room C. Having the client sit across a desk or table to give the client some personal space D. Maintaining a distance of 2 feet or closer between the nurse and client E. Switching on a dim light that will make the room cozier and help the client relax - A. Ensuring that the room is private 127. B. Seeing that distracting objects are removed from the room 128. A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors B. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying C. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort D. Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable - A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors 129. A nurse is preparing to screen a client's vision with the use of a Snellen chart. Which action should the nurse take? A. Tests the right eye, then tests the left eye, and finally tests both eyes together B. Assesses both eyes together, then assesses the right and left eyes separately C. Asks the client to stand 40 feet from the chart and read the largest line on the chart D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision - A. Tests the right eye, then tests the left eye, and finally tests both eyes together 130. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? A. Is legally blind B. Has normal vision C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet D. Can read at a distance of 80 feet what a client with normal vision can read at 20 feet - C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet 131. A nurse is examining the peripheral vision of a client using the confrontation test. How should the nurse carry out this procedure? A. Asks the client to discriminate numbers on a chart composed of colored dots B. Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field C. Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field - D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field 132. A nurse performing an eye examination uses an ophthalmoscope to best visualize which area? A. Iris B. Cornea C. Optic disc D. Conjunctiva - C. Optic disc 133. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? A. Normal near vision B. Normal central vision C. Normal peripheral vision D. Normal ocular movements - D. Normal ocular movements 134. A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? A. Ptosis B. Nystagmus C. Scleral icterus D. Exophthalmos - B. Nystagmus 135. A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? A. Myopia B. Hyperopia C. Photophobia D. Accommodation - D. Accommodation 136. An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? A. Loud music B. Use of power tools C. Occupational noise D. Exposure to cigarette smoke - D. Exposure to cigarette smoke 137. A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? A. Pulling the pinna up and back B. Pulling the pinna down and forward C. Tipping the client's head down and toward the examiner D. Tipping the client's head down and away from the examiner - A. Pulling the pinna up and back 138. A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client - B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested 139. A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? A. On the client's teeth B. On the client's forehead C. On the client's mastoid bone D. On the midline of the client's skull - C. On the client's mastoid bone 140. A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? A. Redness and swelling of the tympanic membrane B. An external auditory canal that is longer than normal C. The presence of edema in the external auditory canal D. A yellowish or brownish waxy material in the external auditory canal - D. A yellowish or brownish waxy material in the external auditory canal 141. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? A. Firm pressure B. Pain behind the eyes C. Pain during palpation D. Pressure producing an acute headache - A. Firm pressure 142. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? A. Asking the client to stick out his or her tongue and watching the client for tremors B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands - D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands 143. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? A. Coffee B. A tuning fork C. A wisp of cotton D. An ophthalmoscope - A. Coffee 144. A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? A. Cranial nerve V B. Cranial nerve XII C. Cranial nerves I and II D. Cranial nerves IX and X - D. Cranial nerves IX and X 145. A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? A. Cranial nerve X B. Cranial nerve V C. Cranial nerve IX D. Cranial nerve XII - D. Cranial nerve XII 146. A nurse is preparing to listen to the breath sounds of a client. The nurse should: A. Ask the client to lie prone B. Ask the client to breathe in and out through the nose C. Hold the bell of the stethoscope lightly against the chest D. Listen for at least one full respiration in each location on the chest - D. Listen for at least one full respiration in each location on the chest 147. A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: A. Normal egophony B. Abnormal vesicular breath sounds C. Abnormal bronchophony D. Normal whispered pectoriloquy - C. Abnormal bronchophony 148. A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? A. Harsh B. Hollow C. Tubular D. Rustling - D. Rustling 149. A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: A. Normally heard in the lungs B. Hollow sounds heard over the trachea and larynx C. Rustling sounds heard over the peripheral lung fields D. Abnormal sounds that should not be heard in the lungs - D. Abnormal sounds that should not be heard in the lungs 150. A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? A. Age B. Ethnicity C. Hypertension D. Genetic inheritance - C. Hypertension 151. A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by: A. Palpating the carotid artery in the upper third of the neck B. Palpating both arteries simultaneously to compare amplitude C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery - C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits 152. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the: A. Second left interspace B. Second right interspace C. Left lower sternal border D. Fifth left interspace at the midclavicular line - D. Fifth left interspace at the midclavicular line 153. A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips: A. Behind the knee B. Lateral to the extensor tendon of the big toe C. In the groove between the malleolus and the Achilles tendon D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines - B. Lateral to the extensor tendon of the big toe 154. A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing: A. Venous insufficiency B. Intermittent claudication C. Sore muscles from overexertion D. Muscle cramps related to musculoskeletal problems - B. Intermittent claudication 155. A nurse conducting a peripheral vascular assessment performs the Allen test. The n