Heart and Peripheral Vascular Assessment
The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?
What is the mitral area?
The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?
What is a pleural friction rub
A patient has been on bed rest for a prolonged period. To specifically promote the use of isotonic exercise, the nurse will instruct the patient to
What is turn side to side in bed?
A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose?
What is humidifies the oxygen that is bypassing the client's nose?
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care?
What is the informed consent needs to be obtained from the client?
To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas?
What is in the groove behind the medial malleolus and the Achilles tendon?
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?
What is just under the left clavicle?
An average-size male patient has right-sided hemiparesis, requiring minimal assistance with ambulation. The nurse helps this patient walk by standing at his
What is his right side and holding the gait belt at the patient’s back?
The nurse is told that a client will have an arterial blood gas sample drawn on room air. The nurse is asked to complete the laboratory requisition. The nurse documents on the requisition that the client was receiving how much oxygen for the procedure?
What is 21%?
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?
What is assault?
An inspection of the lower extremities is being performed. The presence of arterial insufficiency is suspected when the nurse observes.
What is cooler skin temperature?
The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over which area?
What are the major bronchi?
A patient with a fractured left femur has been using crutches for the past 6 weeks. The physician tells the patient to begin putting full weight on the left foot when walking. Which gait should the patient be taught to use?
What is four-point?
A flow rate of oxygen of 2 L/minute is provides ____ percent of oxygenation?
What is 28%?
The charge nurse is planning the assignments for the day. Which factors would the nurse remain mindful of when planning the assignments?
What are the acuity level of the clients and the clients' needs and workers' needs and abilities?
The nurse is trying to auscultate heart sounds but cannot hear them clearly. The nurse
What is the nurse should make sure that the diaphragm or bell of the stethoscope is in contact with the skin, ask patients or visitors to refrain from talking, turn down/off TVs and radios, or obtain an amplified stethoscope?
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding?
What is rhythmic respirations with periods of apnea?
While ambulating in the hallway of a hospital, the patient complains of extreme dizziness. The nurse, alert to a syncopal episode, should first
What is lower the patient gently to the floor?
The nurse is working on a respiratory care unit in the hospital. On entering the room of a patient with emphysema, it is noted that the patient is experiencing respiratory distress. The nurse should first
What is provide oxygen at 2 L/minute via nasal cannula?
The nurse manager is planning the clinical assignments for the day. Which staff members would not be assigned to care for a client with herpes zoster?
What are the nurse who never had chicken pox and the nurse who never received the varicella-zoster vaccine?
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
What is elevated pressure related to heart failure?
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?
What are wheezes?
A patient is getting up for the first time after a period of bed rest. The nurse should first
What is check the blood pressure?
The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the patients, which is
What is restlessness?
The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral pressure injury. Which is the most appropriate activity for the RN to delegate to the LPN?
What is place the client in a side-lying position?