Respiratory
The nurse is assessing the respiratory rate of a client who is sleeping. After 30 seconds, the nurse notes that the respiratory pattern is irregular with a rate of 10/min. Which of the following actions should the nurse take?
1) Document the client's respiratory pattern as hyperventilation
2) Document the respiratory rate as 10/min and irregular
3) Wake the client and recount the respirations
4) Recount the respirations for 60 seconds.
Recount the respirations for 60 seconds
The nurse is assessing a client and suspects the client may be experiencing intimate partner violence (IPV). Which of the following findings would be consistent with IPV? Select all that apply.
1) Delayed seeking treatment for 2 days after sustaining an injury
2) Was hospitalized for a broken foot and ankle 5 years ago
3) Received treatment for viral pneumonia last month
4) Reports living in a limited-income household
5) Has hypertension and chronic pain
Delayed seeking treatment for 2 days after sustaining an injury
Has hypertension and chronic pain
The nurse is caring for a client with pitting edema of the lower extremities. The lower extremities appear swollen. When pressure is applied to the lower extremities, there is a 6-mm indentation that lasts for 75 seconds. The nurse should document the client's edema as grade
1) 1
2) 2
3) 3
4) 4
3
The nurse is assessing a client who has a cyst in the cerebellum. The nurse should expect that the client may experience
1) Uncoordinated motor movements
2) Sleep disturbances
3) Hearing impairment
4) Bradycardia
Uncoordinated motor movements
The nurse is assessing a client's nutritional status. Which of the following findings would indicate that the client may be experiencing a nutritional deficiency? Select all that apply.
1) Dry eyes
2) Excessive hair loss
3) Smooth, red tongue
4) Muscle wasting in the legs
5) Bull's-eye rash on the back
Excessive hair loss
Muscle wasting in the legs
The nurse in the emergency department is caring for assigned clients. It would require immediate follow-up if a
1) 9-year-old client is observed leaning forward with their elbows resting on the knees
2) 19-year-old client has hollow breath sounds auscultated over the trachea
3)70-year-old client is experiencing dyspnea after exertion
4) 92-year-old client has an exaggerated posterior curvature of the thoracic spine
9-year-old client is observed leaning forward with the elbows resting on their knees
The nurse is assessing an 82-year-old client who lives with a caregiver. The nurse notes that the client is underweight and has poor hygiene and 2 pressure injuries. Which of the following actions would be a priority for the nurse to take?
1) Perform a safety screening.
2) Confront the client's caregiver.
3) Order a meal tray for the client.
4) Consult with the wound care nurse.
Perform a safety screening.
1) jugular venous distension
2) increased myocardial elasticity
3) calcification of the heart valves
4) decreased systolic blood pressure
The nurse is caring for a client who had an ischemic stroke affecting the Wernicke area of the brain. The nurse should recognize that the client may experience
1) visual disturbances
2) personality changes
3) sensory function alterations
4) difficulty understanding speech
The nurse is performing a general survey assessment for a client. Which of the following findings would require follow-up? Select all that apply
1) Demonstrates disorganized speech
2) Appears clean and groomed3
3) Maintains eye contact
4) Grimaces when touched
5) Refuses to answer questions
Demonstrates organized speech
Grimaces when touched
Refuses to answer questions
The nurse is assisting while a client undergoes a bedside procedure with moderate sedation. During the procedure, the client becomes restless and cries out, "Help Me!" Which of the following actions would be the priority for the nurse to take?
1) Administer morphine.
2) Check the client's pulse oximetry reading.
3) Administer midazolam
4) Open the client's airway using a head tilt-chin lift
Check the client's pulse oximetry reading
The nurse is caring for a client who has been experiencing intimate partner violence for several years. The nurse should recognize that the client is at risk for
1) Malnutrition
2) Schizophrenia
3) Pressure injuries
4) Major depressive disorder
Major depressive disorder
The nurse is performing a focused assessment of the heart for a client. Which of the following questions should the nurse ask? Select all that apply
1) "Do you experience dyspnea while at rest?"
2) "Do you experience fatigue despite getting adequate sleep?"
3) "Are you experiencing joint stiffness that is worse upon awakening?"
4) "Do you have a family history of cardiovascular disease?"
5) "Have you had any gradual vision loss?"
"Do you experience dyspnea while at rest?"
"Do you experience fatigue despite getting adequate sleep?"
"Do you have a family history of cardiovascular disease?"
The nurse is gathering equipment to assess the function of cranial nerve IX for a client. The nurse should obtain a
1) penlight
2) cotton ball
3) tuning fork
4) tongue depressor
Tongue Depressor
The quality improvement nurse is reviewing documentation in client medical records. Which of the following entries in a client medical record would reflect appropriate documentation practices?
1) 1 inch (2.5 cm) area of bright red blood on abdominal surgical dressing on arrival to unit. Health care provider at the bedside.
2) Indwelling urinary catheter inserted by nurse in the emergency department 2 hours ago using sterile technique.
3) Client seems to be experiencing nausea but has not asked for PRN antiemetic medication.
4) Client appears too thin. Client is likely experiencing anorexia nervosa.
1 inch (2.5 cm) area of bright red blood on abdominal surgical dressing on arrival to unit. Health care provider at the bedside.
79-year-old client arrived via ambulance. Alert and oriented. Respirations unlabored. Coarse crackles auscultated bilaterally. Pale skin and mucosa. Cyanosis of nail beds and lips. Delayed capillary refill. Chest x-ray positive for pneumonia. T 99 F, P 122, RR 21, BP 100/76 mm Hg, SpO2 83% on room air.
What findings support the diagnosis of hypoxemia?
P 122
The nurse has attended a staff education program about substance use disorder. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply
1) "Opioid intoxication causes high blood pressure and tachycardia."
2) "Alcohol use in pediatric clients can interfere with brain development."
3) "Cocaine intoxication causes grandiosity and aggression toward others."
4) "Chronic cannabis use increases the risk for developing cardiovascular disease."
5) "Amphetamine withdrawal causes psychomotor agitation and dysfunctional sleep patterns."
"Alcohol use in pediatric clients can interfere with brain development."
"Cocaine intoxication causes grandiosity and aggression toward others."
"Amphetamine withdrawal causes psychomotor agitation and dysfunctional sleep patterns."
The nurse is assessing a client with suspected intermittent claudication. Which of the following findings would support a diagnosis of intermittent claudication?
1) Cramping sensation in the legs that resolves with rest
2) Discoloration of the fingers when exposed to cold weather
3) Ulcer on the left foot with surrounding numbness and tingling
4) Edema of the right arm with surrounding warmth and tenderness
Cramping sensation in the legs that resolves with rest
The nurse is teaching clients at a community health fair about prevention and early detection of stroke. Which of the following information should the nurse include? Select all that apply
1) "Smoking increases the risk for stroke."
2) "Facial drooping while smiling may be a sign of stroke."
3) "Emergency services should be notified if stroke symptoms persist for more than 1 hour."
4) "Blood pressure monitoring reduces the risk for stroke."
5) "Resting hand tremors may indicate a stroke."
"Smoking increases the risk for stroke."
"Facial drooping while smiling may be a sign of stroke."
"Blood pressure monitoring reduces the risk for stroke."
Transferred from intensive care unit 10 minutes ago. Seems unnecessarily anxious about the transfer. Assessment completed on arrival. Reports chest pain beginning on transfer. States, "I feel pressure in my chest." Appears to be experiencing severe pain. 12-lead ECG shows sinus tachycardia. Health care provider at bedside. Verbal order received for pain medication. T 98.5 F, P 122, RR 26, BP 188/101 mm Hg, SpO2 of 93% on room air.
Which reflect appropriate documentation practices?
Reports chest pain beginning on transfer
"I feel pressure in my chest"
12-lead ECG
The nurse has attended a staff education program about equipment used during respiratory assessments. Which of the following statements by the nurse would indicate a correct understanding of the program?
1) "A peak flow meter measures the peak inspiratory flow rate."
2) "A stethoscope can be used to palpate the lungs."
3) "Incentive spirometry measures the volume of inspired air."
4) "Pulse oximetry is used to monitor lung expansion."
"Incentive spirometry measures the volume of inspired air. "
The nurse is reviewing new laboratory test orders for a client with suspected chronic alcohol use disorder. Which of the following laboratory tests is used to determine chronic alcohol use disorder?
1) serum protein gamma-glutamyl transferase level
2) blood alcohol concentration
3) serum troponin level
4) BNP
Serum protein gamma-glutamyl transferase level
The nurse is caring for an older adult client. Which of the following should the nurse recognize as an age-related finding? Select all that apply
1) Palpable chest bruit and thrill
2) Thickened cardiac valves
3) Ventricular hypertrophy
4) Thinning of the blood vessels and myocardium
5) Jugular vein distention
Thickened cardiac valves
Ventricular hypertrophy
The nurse is performing a neurological assessment for a client. Which of the following questions should the nurse ask? Select all that apply
1) "Are you experiencing any muscle weakness?"
2) "Do you experience hand tremors while resting?"
3) "Have you experienced a seizure within the last year"
4) "Are you experiencing any numbness and tingling in your arms"
5) "Have you noticed any swelling of the lymph nodes in your neck?"
6) "Have you observed a change in the size or color of any moles on your skin?"
"Are you experiencing any muscle weakness?"
"Do you experience hand tremors while resting?"
"Have you experienced a seizure within the last year?"
"Are you experiencing any numbness and tingling in your arms?"
The nurse has attended a staff education program about providing culturally competent care. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply
1) "Spirituality is defined by structured practices and beliefs that often involve rituals."
2) "I will assess the client's preferred methods for nonverbal communication."
3) "Personal religious and cultural beliefs should be shared with clients."
4) "I should be aware of any personal bias toward clients of different backgrounds."
5) "I should ask clients if there is a specific family member who makes all medical decisions."
I should be aware of any personal bias toward clients of different backgrounds
I should ask clients if there is a specific family member who makes all medical decisions