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The nurse is preparing to perform a physical examination on a client who has
cardiopulmonary disease. Knowing this about the client, the nurse is alert for
the presence of which of the following when checking the client's nails? Select
one:
a. Clubbing
b. Bands in nailbeds
c. Yellow discoloration
d. Splinter hemorrhages - ANSWER A- clubbing
The nurse is auscultating the client's lungs and notes normal vesicular sounds as
being which of the following?
Select one:
a. Medium-pitched blowing sounds with inspiration equalling expiration
b. Loud, high-pitched, hollow sounds with expiration longer than inspiration
c. Soft, breezy, low-pitched sounds with longer inspiration
d. Sounds created by air moving through small airways - ANSWER c. Soft,
breezy, low-pitched sounds with longer inspiration
During the physical examination, the nurse should use which part of the hand to
assess characteristics such as consistency, contour, and texture in the client's
glands? Select one:
a. Dorsum of the hand
b. Pads of the fingers
c. Palmar surface of the hand
d. Fingertip grasp of the tissue - ANSWER b. Pads of the fingers
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If a low-pitched murmur is suspected with prior assessment, which of the
following is the best position for the client when the nurse auscultates the apical
site? Select one: a. Sitting up
b. Standing
c. Lying on the left side
d. Dorsal recumbent - ANSWER c. Lying on the left side
, The nurse suspects that an older adult client may have pneumonia. Older adult
clients may react differently to infectious processes, so the nurse is alert to
atypical signs and symptoms, such as which one of the following?
Select one:
a. Hypotension
b. Confusion
c. Erythema
d. Chills - ANSWER b. Confusion
The nurse recognizes the appropriate procedures for sterile asepsis. Of the
following, which action is consistent with sterile asepsis?
Select one:
a. Clean forceps may be used to move items on the sterile field.
b. Sterile fields may be prepared well in advance of the procedures.
c. The first small amount of sterile solution should be poured and discarded.
d. Wrapped sterile packages should be opened starting with the flap closest to
the nurse. - ANSWER c. The first small amount of sterile solution should be
poured and discarded.
Which of the following positions maximizes the nurse's ability to assess
the client's upper body for symmetry? Select one: a. Sitting b. Supine
c. Prone
d. Dorsal recumbent - ANSWER a. Sitting
The nurse is observing a new staff member work with the client. Of the
following activities, which one has the greatest possibility of contributing to a
nosocomial infection and requires correction?
Select one:
a. Washing hands before applying a dressing
b. Taping a plastic bag to the bed rail for tissue disposal
c. Placing a Foley catheter bag on the bed when transferring a client
d. Using alcohol to cleanse the skin before starting an intravenous line -
ANSWER c. Placing a Foley catheter bag on the bed when transferring a
client
The client has a 15-cm laceration on his right forearm and an infection develops.
Which of the following is a sign of an acute inflammatory process?