Saunders Comprehensive Review 100%
CORRECT!!
The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over
which area? Click on the image to indicate your answer. - (ANSWER)Apical pulse
A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical
examination after experiencing unusual fatigue over the last several weeks. The client's height is
5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows:
temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute.
The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8
mmol/L). Which question should the nurse ask the client first? - (ANSWER)"When was the last
time you had your blood pressure checked?"
The nurse in the health care clinic is performing a neurological assessment and is testing the
motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse
implement to test the motor function of this nerve? - (ANSWER)Separate the client's jaw by
pushing down on the chin.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best
observe these lesions in which body area? - (ANSWER)Oral mucosa
Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral
mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in
the palms of the hands and soles of the feet.
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item
needed to perform this test? - (ANSWER)A tuning fork
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen
chart is 20/30. How should the nurse explain these results to the client? - (ANSWER)"You can
read at a distance of 20 feet (6 meters) what a person with normal vision can read at 30 feet (9
meters)."
The nurse is performing an abdominal assessment on a client. The nurse determines that which
finding should be reported to the health care provider (HCP)? - (ANSWER)Pulsation between
the umbilicus and the pubis
The nurse is performing a physical examination on a hospitalized client. On abdominal
assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse documents
that which sound is heard? - (ANSWER)Normal bowel sounds
Page 1 of 10
, Rationale:Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring
irregularly between 5 and 30 times a minute. A bruit is a pulsatile blowing sound and occurs with
stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched, rushing,
tinkling sounds that signal increased motility. Hypoactive bowel sounds are either diminished or
absent, signal decreased motility, and occur after surgery or with inflammation of the
peritoneum.
The nurse is preparing to perform an abdominal examination on a client. The nurse should place
the client in which position for this examination? - (ANSWER)Supine with the head raised
slightly and the knees slightly flexed
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history
of tobacco use. What is the most important element of the nurse's focused assessment of the
client's smoking history? - (ANSWER)Number of pack-years
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular
contractions and is placed on metoprolol tartrate. The client returns to the health care provider's
(HCP's) office 1 month later for a checkup. The nurse should implement which type of database
when performing an assessment? - (ANSWER)Follow-up database
The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse
should next ask the client to take which action? - (ANSWER)Identify 3 numbers or letters traced
in the client's palm.
After performing an initial abdominal assessment on a client, the nurse documents that the bowel
sounds are normal. Which description best describes normal bowel sounds? -
(ANSWER)Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
The nurse is preparing to perform an otoscopic examination on an adult client. Which action
should the nurse take to perform this examination? - (ANSWER)Pull the pinna up and back
before inserting the speculum.
The nurse is making an initial home visit to a client who was recently discharged from the
hospital after treatment for a myocardial infarction. The nurse should use which type of database
initially to obtain information from the client? - (ANSWER)A complete health database
The nurse is preparing to interview a client to collect data about the client's health history. The
nurse should take which actions to make sure that the physical environment is ready? Select all
that apply. - (ANSWER)- Provide sufficient lighting.
- Set the room temperature at a comfortable level.
- Make sure that the client will be seated comfortably at eye level with the nurse.
Rationale:When preparing the physical environment for an interview, the nurse should provide
sufficient lighting for the client and nurse to see each other. The nurse should avoid having the
client face a strong light because the client would have to squint into the full light. The nurse
should set the room temperature at a comfortable level. The nurse should arrange seating so that
Page 2 of 10
CORRECT!!
The clinic nurse is preparing to assess the client's apical pulse. The nurse correctly palpates over
which area? Click on the image to indicate your answer. - (ANSWER)Apical pulse
A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical
examination after experiencing unusual fatigue over the last several weeks. The client's height is
5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows:
temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute.
The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8
mmol/L). Which question should the nurse ask the client first? - (ANSWER)"When was the last
time you had your blood pressure checked?"
The nurse in the health care clinic is performing a neurological assessment and is testing the
motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse
implement to test the motor function of this nerve? - (ANSWER)Separate the client's jaw by
pushing down on the chin.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best
observe these lesions in which body area? - (ANSWER)Oral mucosa
Rationale:In a dark-skinned client, petechiae are best observed in the conjunctivae and oral
mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in
the palms of the hands and soles of the feet.
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item
needed to perform this test? - (ANSWER)A tuning fork
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen
chart is 20/30. How should the nurse explain these results to the client? - (ANSWER)"You can
read at a distance of 20 feet (6 meters) what a person with normal vision can read at 30 feet (9
meters)."
The nurse is performing an abdominal assessment on a client. The nurse determines that which
finding should be reported to the health care provider (HCP)? - (ANSWER)Pulsation between
the umbilicus and the pubis
The nurse is performing a physical examination on a hospitalized client. On abdominal
assessment, the nurse listens to the bowel sounds and hears these sounds. The nurse documents
that which sound is heard? - (ANSWER)Normal bowel sounds
Page 1 of 10
, Rationale:Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring
irregularly between 5 and 30 times a minute. A bruit is a pulsatile blowing sound and occurs with
stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched, rushing,
tinkling sounds that signal increased motility. Hypoactive bowel sounds are either diminished or
absent, signal decreased motility, and occur after surgery or with inflammation of the
peritoneum.
The nurse is preparing to perform an abdominal examination on a client. The nurse should place
the client in which position for this examination? - (ANSWER)Supine with the head raised
slightly and the knees slightly flexed
The nurse is providing care to a client admitted for coronary artery disease (CAD) and a history
of tobacco use. What is the most important element of the nurse's focused assessment of the
client's smoking history? - (ANSWER)Number of pack-years
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular
contractions and is placed on metoprolol tartrate. The client returns to the health care provider's
(HCP's) office 1 month later for a checkup. The nurse should implement which type of database
when performing an assessment? - (ANSWER)Follow-up database
The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse
should next ask the client to take which action? - (ANSWER)Identify 3 numbers or letters traced
in the client's palm.
After performing an initial abdominal assessment on a client, the nurse documents that the bowel
sounds are normal. Which description best describes normal bowel sounds? -
(ANSWER)Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
The nurse is preparing to perform an otoscopic examination on an adult client. Which action
should the nurse take to perform this examination? - (ANSWER)Pull the pinna up and back
before inserting the speculum.
The nurse is making an initial home visit to a client who was recently discharged from the
hospital after treatment for a myocardial infarction. The nurse should use which type of database
initially to obtain information from the client? - (ANSWER)A complete health database
The nurse is preparing to interview a client to collect data about the client's health history. The
nurse should take which actions to make sure that the physical environment is ready? Select all
that apply. - (ANSWER)- Provide sufficient lighting.
- Set the room temperature at a comfortable level.
- Make sure that the client will be seated comfortably at eye level with the nurse.
Rationale:When preparing the physical environment for an interview, the nurse should provide
sufficient lighting for the client and nurse to see each other. The nurse should avoid having the
client face a strong light because the client would have to squint into the full light. The nurse
should set the room temperature at a comfortable level. The nurse should arrange seating so that
Page 2 of 10
