Health Assessment
What abnormal lung sound would most likely indicate fluid in the lungs
Crackles
What electrolyte imbalance occurs due to a sodium deficit in ECF caused by loss of sodium or gain of water?
hyponatremia
A nurse is preparing to discontinue NPO (nothing by mouth) status for a client who has been receiving medical treatment for gastrointestinal bleeding. What should the nurse assess before resuming oral intake?
The client’s bowel sounds and passage of flatus
A nurse is caring for a client who is 2 weeks postpartum. The nurse notices the client appears withdrawn, expresses feelings of sadness, and seems disinterested in her baby. The nurse should be most concerned about:
Postpartum depression
When taking a patient's BP, what should they not do?
cross their legs
A nurse is performing a cardiac assessment on a client. What five areas should the nurse auscultate to assess the heart valves and listen for normal and abnormal heart sounds
Aortic area, Pulmonic area, Erb’s point, Tricuspid area, Mitral area
A nurse is caring for a postoperative client who is at risk for developing atelectasis. What interventions are most effective in preventing atelectasis in this client?
deep breathing exercises and using an incentive spirometer
A nurse is caring for a client who has sustained a traumatic brain injury (TBI). The healthcare provider orders the use of the Glasgow Coma Scale (GCS) to assess the client's neurological status. The nurse understands that the GCS is primarily used to:
Assess the level of consciousness and neurological function
A nurse is preparing for the immediate care of a newborn after a vaginal delivery. What action is the nurse’s priority?
drying the newborn
The nurse is performing an initial assessment on a client in an emergency situation. What is the correct meaning of the acronym ABCs in the context of emergency care?
airway, breathing, circulation
A nurse is preparing to perform an ear exam on a 5-year-old child. What is the correct technique for positioning the ear to visualize the tympanic membrane?
pull the ear down and back
A nurse is educating a client who has been prescribed an angiotensin II receptor blocker (ARB) for hypertension. What side effect should the nurse inform that client about?
a persistent dry cough
Is the following statement true or false?
Brain tumor classification is based on location and histologic characteristics.
TRUE
A nurse is caring for a client 2 hours postpartum. The nurse notes a heavy amount of bleeding, with clots. The nurse suspects postpartum hemorrhage (PPH). What is the first action the nurse should take?
A nurse is preparing to administer a medication via IV push to a client. What medication should never be administered by IV push?
Potassium
This technique, used to assess joint mobility and function, involves passive or active movement of a joint through its full range of motion and is often tested in patients with musculoskeletal complaints.
range of motion
A nurse is educating a pregnant woman who has been prescribed a tetracycline antibiotic for an infection. The nurse should inform the client that tetracyclines are contraindicated during pregnancy and in young children due to what risk?
Teeth discoloration and staining
A nurse is caring for a client who is receiving immunosuppressive therapy following a kidney transplant. What is the priority assessment for the nurse to monitor in this client?
What medications do newborns receive soon after birth?
Vit K, Hep B, Erythromycin
What is the correct order when assessing the abdomen
inspect, auscultate, percuss, palpate
A nurse is assessing a client’s ability to shrug their shoulders and turn their head against resistance. Which cranial nerve is being tested?
Cranial nerve XI (Accessory nerve)
This medication, used in the treatment of acute asthma exacerbations, works by relaxing bronchial smooth muscles through beta-2 adrenergic agonism, and its side effects can include tachycardia and tremors.
albuterol
A nurse is caring for a client with suspected bacterial meningitis. The nurse notes that the client is complaining of severe neck pain and has difficulty touching their chin to their chest. The nurse recognizes that this is indicative of:
a positive Kernig sign
A nurse is caring for a laboring client and notices that the fetal heart rate (FHR) is variable decelerations. What action should the nurse take first?
change the client's position
This condition is characterized by a deficiency of antidiuretic hormone (ADH), leading to excessive urine production, increased thirst, and electrolyte imbalances, often associated with damage to the pituitary or hypothalamus.
diabetes insipidus