Basic Physical Assessment NCLEX Questions

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? a) Insert an NG tube and connect to suction. b) Obtain vital signs. c) Document history of the symptoms. d) Assess bowel sounds and abdominal tenderness - Answer- Obtain Vital Signs Which of the following nursing assessment findings in a client with septic shock would require immediate intervention? a) Client experiencing polydipsia b) Urine output of 90 mL of dark, concentrated urine for the past 6 hours c) Fluctuation of temperature d) Confusion when listening to explanations of procedures - Answer- • "When did the rash start?" • "Are you allergic to any medications, foods, or pollen?" • "What have you been using to treat the rash?" • "Have you recently traveled outside the country?" An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms? a) serum osmolality b) serum sodium c) urine specific gravity d) platelet count - Answer- Urine output of 90 mL of dark, concentrated urine for the past 6 hours The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8° F (38.8° C). The nurse should: a) tell the assistant to change thermometers and retake the temperature.