Answers
The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness -
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correct answersPressing the affected area firmly with one hand, releasing pressure quickly, and noting any
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tenderness on release e e
The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices
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Cheyne-Stokes respirations. Cheyne-Stokes respirations are: - correct answersprogressively deeper breaths
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followed by shallower breaths with apneic periods.
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The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2,
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28 mm Hg; PaO2, 70 mm Hg; and HCO3-, 24 mEq/L. What do these values indicate? - correct
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answersRespiratory alkalosis e
Why shouldn't the nurse palpate both carotid arteries at one time? - correct answersIt may cause severe
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bradycardia.
The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential
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between these two pulses is called: - correct answersthe pulse deficit.
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, A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the
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client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment
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should proceed in which order? - correct answersAuscultation, percussion, and palpation
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The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major
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disadvantage of barbiturate use? - correct answersPotential for drug dependence e e e e e e e e e
During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of
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data? - correct answersObjective
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A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two
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readings necessary? - correct answersTo compensate for the effects of activity on the heart rate
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To evaluate a client's posterior tibial pulse, where should the nurse palpate? - correct answersOn the inner
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aspect of the ankle, below the medial malleolus
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At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse
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detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? - correct
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answersNotify the physician immediately of these findings e e e e e e
When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The
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nurse takes a quick health history that includes: - correct answersthe history of the present problem, allergies,
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medications, and recent major operations.
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The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other
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abnormal breath sounds? - correct answersA rub occurs during both inspiration and expiration and produces
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a squeaking or grating sound.
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When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant.
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Based on this finding, the nurse suspects: - correct answersnothing abnormal.
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The nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse
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should position the client's ear by pulling the: - correct answershelix up and back.
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