Acute Care Exam 2 (2023 Update)
The nurse prepares to conduct a general survey on an adult patient. Which assessment
is performed first while the nurse
... [Show More] initiates the nurse-patient relationship?
1) Appearance and behavior
2) Measurement of vital signs
3) Observing specific body systems
4) Conducting a detailed health history - ANS-1) Appearance and behavior Correct
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate
if the child has a fever. Which information is important for the nurse to include?
1) Place the palm of the hand on the child's back.
2) Lightly touch the child's forehead with the fingertips.
3) Place the back of your hand against the child's forehead and then on the back of the
neck.
4) Use the pads of your fingers and press against the child's neck and over the thorax. -
ANS-3) Place the back of your hand against the child's forehead and then on the back
of the neck.
While assessing the adult patient's lungs, the nurse identifies the following assessment
findings. Which finding should be reported to the health care provider?
1) Respiratory rate: 14
2) Pain reported when palpating posterior lower thorax
3) Thorax rising and falling symmetrically for right and left lungs
4) Vesicular breath sounds heard with auscultation of peripheral lung fields - ANS-2)
Pain reported when palpating posterior lower thorax
The nurse is teaching a young female patient to practice good skin health. Which
information is important for the nurse to include?
1) Avoid sunbathing between 3 PM and 7 PM.
2) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
3) Call the health care provider for the presence of a mole on an arm or leg that appears
uniformly brown.
4) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor. -
ANS-2) Oral contraceptives and antiinflammatories make the skin more sensitive to the
sun.
As a nurse prepares to provide morning care and treatments, it is important to question
a patient about a latex allergy before which intervention? (Select all that apply.)
1) Applying adhesive tape to anchor a nasogastric tube
2) Inserting a rubber Foley catheter into the patient's bladder
3) Providing oral hygiene using a standard toothbrush and toothpaste
4) Giving an injection using plastic syringes with rubbercoated plungers
5) Applying a transparent wound dressing - ANS-1) Applying adhesive tape to anchor a
nasogastric tube
2) Inserting a rubber Foley catheter into the patient's bladder
4) Giving an injection using plastic syringes with rubbercoated plungers
The nurse is assessing a patient who returned 3 hours ago from a cardiac
catheterization, during which the large catheter was inserted into the patient's femoral
artery in the right groin. Which assessment finding would require immediate follow-up?
1) Palpation of a femoral pulse with a heart rate of 76
2) Auscultation of a heart murmur over the left thorax
3) Identification of mild bruising at the catheter insertion site
4) Palpation of a right dorsalis pedis pulse with strength of +1 - ANS-4) Palpation of a
right dorsalis pedis pulse with strength of +1
The patient reports having a sore throat, coughing, and sneezing. While performing a
focused assessment, which finding supports the patient's reported symptoms related to
upper respiratory infection?
1) Buccal mucosa is moist and dark pink.
2) Respiratory rate is 18, rhythm is even.
3) Retropharyngeal lymph nodes are enlarged and firm.
4) Inspection with a tongue depressor on the posterior tongue causes gagging. - ANS-3)
Retropharyngeal lymph nodes are enlarged and firm.
The nurse is teaching a patient with poor arterial circulation about checking blood flow in
the legs. Which information should the nurse include? (Select all that apply.)
1) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
2) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee
3) When there is poor arterial blood flow, the leg is generally warm to the touch.
4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. -
ANS-1) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
How should the patient be positioned to best palpate for lumps or tumors during an
examination of the right breast?
1) Supine with both arms overhead with palms upward
2) Sitting with hands clasped just above the umbilicus
3) Supine with the right arm abducted and hand under the head and neck
4) Lying on the right side, adducting the right arm on the side of the body - ANS-3)
Supine with the right arm abducted and hand under the head and neck
The nurse is planning a staff education conference about abdominal assessment.
Which point is important for the nurse to include?
1) The aorta can be felt using deep palpation in the upper abdomen near the midline
2) The patient should be sitting to best determine the contour and shape of the
abdomen.
3) Always wear gloves when palpating the skin on the patient's abdomen.
4) Avoid palpating the abdomen if the patient reports any discomfort or feelings of
fullness. - ANS-1) The aorta can be felt using deep palpation in the upper abdomen
near the midline
The nurse is teaching a patient how to perform a testicular self-examination. Which
statement by the nurse is correct?
1) "The testes are normally round and feel smooth and rubbery."
2) "The best time to do a testicular self-examination is before your bath or shower."
3) "Perform a testicular self-examination weekly to detect signs of testicular cancer."
4) "Since you are over 40 years old, you are in the highest risk group for testicular
cancer." - ANS-1) "The testes are normally round and feel smooth and rubbery."
The patient is assessed for range of joint movement. He or she is unable to move the
right arm above the shoulder. How should the nurse document this finding?
1) Patient was not able to flex arm at shoulder.
2) Extension of right arm is limited.
3) Patient's abduction of right arm was limited to 100 degrees.
4) Internal rotation of right arm is limited to less than 90 degrees. - ANS-3) Patient's
abduction of right arm was limited to 100 degrees.
ID: 41140170
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse
ask the patient to perform?
1) "Tell me where you are."
2) "What can you tell me about your illness?"
3) "Repeat these numbers back to me: 7...5...8."
4) "What does this mean: 'A stitch in time saves nine? ' " - ANS-4) "What does this
mean: 'A stitch in time saves nine? ' "
The nurse teaches a patient about cranial nerves to help explain why the patient's right
side of the mouth droops instead of moving up into a smile. What nerve does the nurse
explain to the patient?
1) VII — Facial
2) V — Trigeminal
3) XII — Hypoglossal
4) XI— Spinal accessory - ANS-1) VII — Facial
The nurse is planning to teach the student nurse how to assess the hydration status of
an older adult. Which techniques are appropriate for this situation? (Select all that
apply.)
1) Inspect the lips and mucous membranes to determine if they are moist.
2) Pinch the skin on the back of the hand to see if the skin tents.
3)Check the patient's pulse and blood pressure.
4) Weigh the patient daily. - ANS-1) Inspect the lips and mucous membranes to
determine if they are moist
3)Check the patient's pulse and blood pressure
4) Weigh the patient daily
The nurse is having difficulty reading a physician's order for a medication. He or she
knows that the physician is very busy and does not like to be called. What is the most
appropriate next step for the nurse to take?
1) Call a pharmacist to interpret the order
2) Call the physician to have the order clarified
3) Consult the unit manager to help interpret the order
4) Ask the unit secretary to interpret the physician's handwriting - ANS-2) Call the
physician to have the order clarified
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication
does the nurse give him or her?... [Show Less]