Nursing 112 Exam 2 Questions With Complete Solutions
30-year-old janitor from Russia tells the nurse in the clinic that
he drinks a fifth of vodka daily and that he's had a recent weight
gain of 3 lb (1.35 kg) in 3 days. Further questioning by the nurse
reveals that he was an intravenous drug user in the past but is
now "clean." His sclerae and skin have a yellowish tinge, and he
has a large abdominal girth. Which assessment finding supports
the nurse's conclusion that the client has liver dysfunction?
Correct Answer Jaudice
A 33-year-old male client returns to the medical-surgical unit
following a thyroidectomy. Which assessment finding requires
an immediate intervention by the nurse? Correct Answer The
client makes noises when he breathes
A 34-year-old client of Asian descent has been hospitalized for
the past 3 days with a diagnosis of hepatitis B. The nurse is
planning a head-to-toe assessment of the client and understands
that the characteristics of an acute hepatitis infection are
jaundice, nausea and vomiting, joint pain, rashes, and elevations
in serum liver function tests. Where would be the best location
for the nurse to observe jaundice in this client? Correct Answer
scalera of the eye
A 56-year-old client with Mexican heritage has a diagnosis of
heart failure. The nurse's morning lung assessment of the client
reveals crackles in the mid to lower lungs and respiratory rate of
32. The nurse notices that the client is restless, and his skin has
an ashen appearance. Which nursing action is the priority
intervention? Correct Answer measure pulse oximetry
,A 57-year-old male client is admitted to the medical unit with a
3-day history of sharp, nonradiating epigastric pain and
vomiting. He denies seeing blood in his stool. When assessing
this client's abdomen, what assessment technique would the
nurse perform last? Correct Answer PALPATATIONS
A 66-year-old female client is reporting abdominal pain. The
nurse assesses the client's abdomen by first inspecting the
abdomen. What should the nurse do next? Correct Answer
Auscultate the abdomen
A 7-year-old child is admitted to the emergency department with
a tentative diagnosis of asthma. Which assessment requires a
priority intervention by the nurse? Correct Answer stridor
A client has been reporting persistent headaches. Which is an
example of subjective data? Correct Answer a 4 out of 10 pain
A client has sustained head trauma. The nurse uses the Full
Outline of Un-responsiveness (FOUR) coma scale to determine
the presence of increased intracranial pressure and client
outcomes. What component(s) of the assessment will the nurse
document? Select all that apply. Correct Answer eye response
motor response
respiration
brainstem reflexes
A client recently was diagnosed with Bell's palsy and is back to
the clinic for a follow-up visit. What would the nurse observe
during the assessment of cranial nerve VII if the client's
, symptoms are resolving? Correct Answer The movement and
appearance would appear symmetrical as the client smiles,
frowns, and raises the eyebrows.
A client states during the interview that he has pain in his lower
back. He states it is a 10 on a scale of 0 to 10 when he is asked
to turn. The nurse should: Correct Answer avoid a position
change that requires turning
A client who is admitted to the health care facility has been
diagnosed with cerebral edema. Which intravenous solution
needs to be administered to this client? Correct Answer
hypertonic solution
A medication order has ac written after the medication dosage.
What does ac stand for? Correct Answer Before meals
A nurse assesses a client for blood pressure. Which technique
would be used for this assessment? Correct Answer
auscultation
A nurse assesses a client who was administered an opioid
analgesic and finds the client unresponsive to shaking and
stimulation. Which is the nurse's immediate plan of action?
Correct Answer Administer naloxone
A nurse assesses breath sounds for clients presenting at a local
clinic with difficulty breathing. Which sounds would the nurse
document as normal? Select all that apply. Correct Answer
Soft, low-pitched, whispering sounds heard over most of the
lung fields
30-year-old janitor from Russia tells the nurse in the clinic that
he drinks a fifth of vodka daily and that he's had a recent weight
gain of 3 lb (1.35 kg) in 3 days. Further questioning by the nurse
reveals that he was an intravenous drug user in the past but is
now "clean." His sclerae and skin have a yellowish tinge, and he
has a large abdominal girth. Which assessment finding supports
the nurse's conclusion that the client has liver dysfunction?
Correct Answer Jaudice
A 33-year-old male client returns to the medical-surgical unit
following a thyroidectomy. Which assessment finding requires
an immediate intervention by the nurse? Correct Answer The
client makes noises when he breathes
A 34-year-old client of Asian descent has been hospitalized for
the past 3 days with a diagnosis of hepatitis B. The nurse is
planning a head-to-toe assessment of the client and understands
that the characteristics of an acute hepatitis infection are
jaundice, nausea and vomiting, joint pain, rashes, and elevations
in serum liver function tests. Where would be the best location
for the nurse to observe jaundice in this client? Correct Answer
scalera of the eye
A 56-year-old client with Mexican heritage has a diagnosis of
heart failure. The nurse's morning lung assessment of the client
reveals crackles in the mid to lower lungs and respiratory rate of
32. The nurse notices that the client is restless, and his skin has
an ashen appearance. Which nursing action is the priority
intervention? Correct Answer measure pulse oximetry
,A 57-year-old male client is admitted to the medical unit with a
3-day history of sharp, nonradiating epigastric pain and
vomiting. He denies seeing blood in his stool. When assessing
this client's abdomen, what assessment technique would the
nurse perform last? Correct Answer PALPATATIONS
A 66-year-old female client is reporting abdominal pain. The
nurse assesses the client's abdomen by first inspecting the
abdomen. What should the nurse do next? Correct Answer
Auscultate the abdomen
A 7-year-old child is admitted to the emergency department with
a tentative diagnosis of asthma. Which assessment requires a
priority intervention by the nurse? Correct Answer stridor
A client has been reporting persistent headaches. Which is an
example of subjective data? Correct Answer a 4 out of 10 pain
A client has sustained head trauma. The nurse uses the Full
Outline of Un-responsiveness (FOUR) coma scale to determine
the presence of increased intracranial pressure and client
outcomes. What component(s) of the assessment will the nurse
document? Select all that apply. Correct Answer eye response
motor response
respiration
brainstem reflexes
A client recently was diagnosed with Bell's palsy and is back to
the clinic for a follow-up visit. What would the nurse observe
during the assessment of cranial nerve VII if the client's
, symptoms are resolving? Correct Answer The movement and
appearance would appear symmetrical as the client smiles,
frowns, and raises the eyebrows.
A client states during the interview that he has pain in his lower
back. He states it is a 10 on a scale of 0 to 10 when he is asked
to turn. The nurse should: Correct Answer avoid a position
change that requires turning
A client who is admitted to the health care facility has been
diagnosed with cerebral edema. Which intravenous solution
needs to be administered to this client? Correct Answer
hypertonic solution
A medication order has ac written after the medication dosage.
What does ac stand for? Correct Answer Before meals
A nurse assesses a client for blood pressure. Which technique
would be used for this assessment? Correct Answer
auscultation
A nurse assesses a client who was administered an opioid
analgesic and finds the client unresponsive to shaking and
stimulation. Which is the nurse's immediate plan of action?
Correct Answer Administer naloxone
A nurse assesses breath sounds for clients presenting at a local
clinic with difficulty breathing. Which sounds would the nurse
document as normal? Select all that apply. Correct Answer
Soft, low-pitched, whispering sounds heard over most of the
lung fields
