QUESTIONS AND ANSWERS WITH FEEDBACK
A nurse is preparing to perform a comprehensive physical examination of an older adult
client. Which of the following interventions should the nurse use in consideration of the
client's age? (Select all that apply)
A. Expect the session to be shorter than for a younger client.
B. Plan to allow plenty of time for position changes.
C. Make sure the client has any essential sensory aids in place.
D. Tell the client to take their time answering bathroom before beginning the
examination. - B. Plan to allow plenty of time for position changes.
C. Make sure the client has any essential sensory aids in place.
D. Tell the client to take their time answering bathroom before beginning the
examination.
A nurse in a provider's office is performing a physical examination of an adult client.
Which part of the hands should the nurse use during palpation for optimal assessment
of skin temperature?
A. Palmar Surface
B. Fingertips
C. Dorsal Surface
D. Base of the fingers - C. Dorsal Surface
A nurse is caring for a client in the emergency department who has an oral body
temperature of 38.3 C (101 F ), pulse rate 114/min, and respiratory rate 22/min. The
client is restless with warm skin. Which of the following interventions should the nurse
take? (Select all that apply.)
A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client's oral fluid intake.
,C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently. - A. Obtain culture specimens before
initiating antimicrobials.
C. Encourage the client to rest and limit activity.
E. Assist the client with oral hygiene frequently.
A nurse is instructing an assistive personnel (AP) about caring for a client who has a
low platelet count. Which of the following instructions is the priory for measuring vital
signs for this client?
A. "Do not measure the client's temperature rectally."
B. "Count the client's radial pulse for 30 seconds and multiply it by 2."
C. "Do not let the client know you are counting their respirations."
D. "Let the client rest for 5 minutes before you measure their blood pressure." - A. "Do
not measure the client's temperature rectally."
(can cause bleeding)
A nurse is instructing a group of assistive personnel in measuring a client's respiratory
rate. Which of the following guidelines should the nurse include? (Select all that apply)
A. Place the client in semi-Fowler's position
B. Have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle before counting the rate.
D. Count the rate for 30 sec if it is irregular.
E. Count and report an sighs the client demonstrates. - A. Place the client in semi-
Fowler's position
B. Have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle before counting the rate.
, A nurse is measuring the blood pressure of a client who has a fractured femur. The
blood pressure reading is 140/94 mm Hg, and the client denies any history of
hypertension. Which of the following actions should the nurse take first?
A. Request a prescription for an anti hypertensive medication
B. Ask client if they are having pain.
C. Request a prescription for an anti anxiety medication.
D. Return in 30 min to recheck the client's blood pressure. - B. Ask client if they are
having pain.
A nurse is performing an admission assessment on a client. The nurse determines the
client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min.
What is the client's pulse deficit? - 16
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which
of the following directions should the nurse include when testing cranial nerve V?
(Select all that apply).
A. "Close your eyes."
B. "Tell me what you can taste."
C. "Clench your teeth."
D. "Raise your eyebrows."
E. "Tell me when you feel a touch." - C and E
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)
A. Palpating the thyroid in the lower half of the neck
B. Visualizing the thyroid on inspection of the neck
C. Hearing a bruit when auscultating the thyroid
D. Feeling the thyroid ascend as the client swallows
E. Finding symmetric extension off the trachea on both sides of the mid-line. - A.
Palpating the thyroid in the lower half of the neck
D. Feeling the thyroid ascend as the client swallows