Saunders Question HA Latest Update
Comprehensive Questions with Correct
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A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client
monitors the status of breath sounds in that area by placing the stethoscope at which location? -
Answer -Just under the left clavicle
A client experiencing "skipped heart beats" is diagnosed with benign premature ventricular contractions
and is placed on metoprolol tartrate (Toprol XL). The client returns to the health care provider's office 1
month later for a checkup. The nurse should implement which type of database when performing an
assessment? - Answer -Follow-up database
A client's vision is tested with a Snellen chart. The results of testing are documented as 20/40. Which
statement is a correct interpretation of the client's test result? - Answer -The client can read at a
distance of 20 feet what a person with normal vision can read at 40 feet.
A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse
perform this test? Arrange the actions in the order that they should be performed. All options must be
used. - Answer -1) Stands 2 to 3 feet in front of and faces the client
2) Asks the client to cover one eye
3) Examiner covers eye opposite to the eye covered by the client
4) The examiner brings in an object gradually from periphery
5) Asks the client to report when object is first noted
A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the
nurse include in the client's focused assessment? - Answer -Self-care needs such as toileting,
feeding, and ambulating
A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the
stethoscope to hear the first heart sound (S1) the loudest? - Answer -Over the fifth intercostal
space in the left midclavicular line
A 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
A nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which
assessment technique should the nurse perform next? - Answer -Listen to bowel sounds in all four
quadrants.
, A nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular
breath sounds, the nurse should place the stethoscope over which area? - Answer -The major
bronchi
A nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm
of the stethoscope over which cardiac site? - Answer -Mitral area
A nurse is reviewing the findings on a physical examination that are documented in a client's record. The
nurse notes which as a piece of documented objective data? - Answer -The client has a rash on the
chest and arms.
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the
student indicates an understanding of this assessment technique? - Answer -"I will ask the client to
extend her legs flat on the bed, and I will gently dorsiflex her foot forward."
A nursing student is performing a respiratory assessment on a female adult client and is assessing for
tactile fremitus. Which action by the nursing student indicates a need for further teaching? -
Answer -Palpating over the breast tissue to assess and compare vibrations from one side to the
other
A nursing student is performing an otoscopic examination in an adult client. The nursing instructor
observes the student perform this procedure. Which observation by the instructor indicates that the
student is using correct technique for the procedure? - Answer -Tilting the client's head slightly
away and holding the otoscope upside down before inserting the speculum
A pericardial friction rub is described as what heart sound? - Answer -a scratchy, leathery heart
sound
A sensorineural hearing loss occurs as a result of a pathological process where? - Answer -1) in the
inner ear
2) a defect in the 8th cranial nerve
3) a defect of the sensory fibers that lead to the cerebral cortex
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 four quadrants
agraphesthesia test - Answer -Identify three numbers or letters traced in the client's palm.
An emergency department nurse is performing an assessment on a child suspected of being sexually
abused. Which assessment data obtained by the nurse most likely supports this suspicion? -
Answer -Difficulty walking
Apneustic respirations - Answer -irregular respirations with pauses at the end of inspiration and
expiration and can indicate a dysfunction in the middle or caudal pons.
Comprehensive Questions with Correct
Answers Guaranteed Pass 100%
A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client
monitors the status of breath sounds in that area by placing the stethoscope at which location? -
Answer -Just under the left clavicle
A client experiencing "skipped heart beats" is diagnosed with benign premature ventricular contractions
and is placed on metoprolol tartrate (Toprol XL). The client returns to the health care provider's office 1
month later for a checkup. The nurse should implement which type of database when performing an
assessment? - Answer -Follow-up database
A client's vision is tested with a Snellen chart. The results of testing are documented as 20/40. Which
statement is a correct interpretation of the client's test result? - Answer -The client can read at a
distance of 20 feet what a person with normal vision can read at 40 feet.
A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse
perform this test? Arrange the actions in the order that they should be performed. All options must be
used. - Answer -1) Stands 2 to 3 feet in front of and faces the client
2) Asks the client to cover one eye
3) Examiner covers eye opposite to the eye covered by the client
4) The examiner brings in an object gradually from periphery
5) Asks the client to report when object is first noted
A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the
nurse include in the client's focused assessment? - Answer -Self-care needs such as toileting,
feeding, and ambulating
A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the
stethoscope to hear the first heart sound (S1) the loudest? - Answer -Over the fifth intercostal
space in the left midclavicular line
A 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
A nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which
assessment technique should the nurse perform next? - Answer -Listen to bowel sounds in all four
quadrants.
, A nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular
breath sounds, the nurse should place the stethoscope over which area? - Answer -The major
bronchi
A nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm
of the stethoscope over which cardiac site? - Answer -Mitral area
A nurse is reviewing the findings on a physical examination that are documented in a client's record. The
nurse notes which as a piece of documented objective data? - Answer -The client has a rash on the
chest and arms.
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the
student indicates an understanding of this assessment technique? - Answer -"I will ask the client to
extend her legs flat on the bed, and I will gently dorsiflex her foot forward."
A nursing student is performing a respiratory assessment on a female adult client and is assessing for
tactile fremitus. Which action by the nursing student indicates a need for further teaching? -
Answer -Palpating over the breast tissue to assess and compare vibrations from one side to the
other
A nursing student is performing an otoscopic examination in an adult client. The nursing instructor
observes the student perform this procedure. Which observation by the instructor indicates that the
student is using correct technique for the procedure? - Answer -Tilting the client's head slightly
away and holding the otoscope upside down before inserting the speculum
A pericardial friction rub is described as what heart sound? - Answer -a scratchy, leathery heart
sound
A sensorineural hearing loss occurs as a result of a pathological process where? - Answer -1) in the
inner ear
2) a defect in the 8th cranial nerve
3) a defect of the sensory fibers that lead to the cerebral cortex
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 four quadrants
agraphesthesia test - Answer -Identify three numbers or letters traced in the client's palm.
An emergency department nurse is performing an assessment on a child suspected of being sexually
abused. Which assessment data obtained by the nurse most likely supports this suspicion? -
Answer -Difficulty walking
Apneustic respirations - Answer -irregular respirations with pauses at the end of inspiration and
expiration and can indicate a dysfunction in the middle or caudal pons.
