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To percuss the upper border of the liver of an adult client, where should the nurse
begin the assessment? At the client's ---------CORRECT ANSWER-----------------Right
MCL, 5th ICS
To palpate for tenderness of an adult client's appendix, the nurse should begin
the abdominal assessment at the client's ---------CORRECT ANSWER-----------------
RLQ
The nurse is assessing the abdomen of an adult client and observes a purple
discoloration at the flanks. The nurse should refer the client to a physician for
which possible condition ---------CORRECT ANSWER-----------------internal bleeding
The nurse is assessing the bowel sounds of an adult client. After listening to each
quadrant, the nurse determines that bowel sounds are not present. The nurse
should refer the client to a physician for possible ---------CORRECT ANSWER----------
-------paralytic ileus
,The nurse is planning to assess a client's abdomen for rebound tenderness. The
nurse should . ---------CORRECT ANSWER-----------------palpate while quickly
releasing pressure
A nurse is introducing herself to a client as the first step of a comprehensive
physical exam. Which of the following strategies should the nurse use with this
client ---------CORRECT ANSWER------------------Use a mix of open and close ended
question
-reduce environmental noise
-perform the general survey before the exam
A nurse in a providers office is documenting his findings following an exam he
performed for a client new to the practice. which if the following parameters
should he include as part of the general survey ---------CORRECT ANSWER------------
------posture
-skin lesions
-speech
A nurse is performing an exam on an older adult client. Which of the following
interventions should the nurse use in consideration of the client's age ---------
CORRECT ANSWER------------------plan to allow plenty of time for position changes
-make sure the client has any essential sensory aids in place
-tell the client to take her time answering questions
, -invite the client to use the bathroom before the exam
A nurse in a family practice clinic is performing a physcial exam on an adult client.
which part of her hands should she use during palpation for optimal assessment
of skin temperature ---------CORRECT ANSWER-----------------dorsal surface
A nurse is caring got an 83 y/o client in the ED who has an oral body temp of
101F, pulse 114, resp 22. He is restless and his skin is warm. which interventions
should the nurse take ---------CORRECT ANSWER------------------obtain culture
specimens before initiating antimicrobials
-encourage the client to rest and limit activity
-assist the client with oral hygiene frequently
A nurse is instructing a group of nursing students in measuring a client's resp rate.
which of the following guidelines should the nurse include ---------CORRECT
ANSWER------------------place the client in a semi-Fowlers position
-have the client rest an arm across the abdomen
-observe one full resp cycle before counting the rate
A nurse who is admitting a client who has a fractured femur obtains a BP reading
of 140/94. client denies history of hypertension. which of the following actions
should the nurse take first ---------CORRECT ANSWER------------------ask the client if
she is having pain