A nurse is collecting data about a client’s respiratory system. Which of the
following breath sounds should the nurse expect to hear over the
... [Show More] periphery
of the major lung fields?
A: Vesicular (Vesicular sounds are soft and low-pitched)
A nurse employs a thorough, systematic method for obtaining OBJECTIVE
data about a client. Which of the following methods should the nurse us to
collect this information?
A: Physical Examination (Physical findings are objective and the nurse should
collect this information in a systematic way.
A nurse is assisting a provider with performing thoracentesis to remove
pleural fluid. How should the nurse position the client?
A: Leaning forward over a pillow.
A nurse is preparing to insert an NG tube for a client who requires enteral
feedings. Which of the following instructions should the nurse give the client
before beginning the procedure?
A: “Raise your index finger if you need to pause during the insertion.”
A nurse is performing a mental-status exam for a client who has
manifestations of dementia. Which of the following directions should the
nurse give the client when evaluating the client’s ability to think abstractly?
A: Discuss the meaning of a common proverb. (Evaluates clients ability to
think abstractly.)
A nurse is presenting an in-service session about nutrition. Which of the
following simple sugars should the nurse identify as the carb found in milk?
A: LACTOSE (Sugar found in milk)
A nurse is assisting with teaching a newly licensed nurse about pain
management in clients age of 65 and older. Which of the following pieces of
information should the nurse include?
A: Clients who are 65 or older are reluctant to report pain. (Might not want to
bother or anger caregivers and might believe that pain is expected.)
A nurse in an oncology clinic is collecting data for a client who is undergoing
treatment for ovarian cancer. Which of the following statements by the client
indicate she is experiencing psychological distress?
A: “I keep having nightmares about my upcoming surgeries.”
A nurse is assisting with the admission of a client to the medical unit and
asks if he has advance directives. The client states “I have a document with
me that names someone who can make health care decisions for me if i am
not able.” The nurse should identify that the client is referring to which of the
following documents?A: Durable Power of Attorney Document (names asurrogate who can make health decisions or the client if the client is unable
to do so)
A nurse is admitting a client who is experiencing an exacerbation of heart
failure. At which of the following times should the nurse initiate discharge
planning?
A: During the admission process. (Nurse should initiate discharge planning as
soon as the client is admitted to the facility.
A nurse discovers that a client received the wrong medication. Which of the
following should the nurse take first?
A: Collect data from the client. (For any side effects from either receiving the
wrong medication or not receiving the prescribed medication”
A nurse is performing eye irrigation for a client who was exposed to smoke
and ash. Which of the following actions should the nurse take?
A: Exert pressure on the bony prominences when holding the eyelids open.
A nurse is measuring the blood pressure for several clients. Which of the
following results is within the expected reference range for blood pressure?
A: 116/70 mmHg
A nurse is assisting a client who has dysphagia at mealtime. Which following
actions should the nurse take?
A: Advise the client to tuck his chin downward.
A nurse is collecting data from a client who is experiencing stress and
anxiety regarding a recent diagnosis. Which of the following findings should
the nurse expect?
A: Increased blood pressure.
A nurse is reinforcing teaching with a Group of unit nurses about the
experiences of clients who are having surgery. Which phase of care begins
with transferring the client to the surgical suite table and ends with the
transfer tp PACU?
A: Intraoperative
A nurse is examining a client’s thyroid gland. Which of the following
instructions should the nurse give the client before inspecting and palpating
this gland?
A: “Turn your head back and swallow.”
A nurse is instructing an assistive personnel AP about proper hand hygiene.
Which of the following statements by the AP indicates an understanding of
the teaching?A: “Sometimes, i should use soap and water rather than an alcohol-based rub
to clean my hands.”
A nurse is preparing to administer medication to a client who has gout. The
nurse discovers that an error was made during the previous shift in which the
client received atenolol instead of allopurinol. Which of the following
interventions is the nurse’s priority?A: Measure the client’s apical pulse
A nurse is collecting data about a client’s peripheral pulses. Which of the
following descriptions should the nurse use to document the finding?
A: Peripheral pulses bilaterally symmetric, equal, and strong in all 4
extremities.
A nurse is reinforcing teaching with a client who has heart failure about
reducing his daily intake of sodium. Which of the following factors is the most
important in determining the client’s ability to learn new dietary habits?A:
The involvement of the client in planning the change
A nurse is supervising a newly licensed nurse who is administering a
controlled substance. Which of the following actions by the newly licensed
nurse indicates an understanding of the procedure?
A: Asking another nurse to observe disposal of an unused portion of the
medication
A nurse is reinforcing teaching with a group of older adults about expected
changes of aging. Which of the following statements by a group member
indicates that the teaching has been effective?
A: “I should expect my heart to rate to take longer to return to normal after
exercise as I get older.”
A nurse at a screening clinic is collecting data for a client who reports a
history of a heart murmur related to aortic valve stenosis. At which of the
following anatomical areas should the nurse place the stethoscope to
auscultation the aortic valve?
A: Second intercostal space to the right of the sternum.
A nurse is changing the dressings for a client recovering from an
appendectomy following a ruptured appendix. The client’s surgical wound is
healing by secondary intention. Which of the following observations should
the nurse report to the provider?A: Halo of erythema on the surrounding of
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