Exam Review

A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia. Exhibits Which of the following actions should the nurse take first?
A)
Administer oxygen via nasal cannula.
B)
Obtain a sputum culture.
C)
Administer an antipyretic medication.
D)
Encourage the client to increase fluid intake.
A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours. Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
✓Auscultate the lungs for adventitious breath sounds
✓Assess for tactile fremitus
✓Lobar pneumonia
✓Respiratory rate and pulse
✓Crackles
Actions to Take
✕Assess for prolonged expiration
✓Auscultate the lungs for adventitious breath sounds
✓Assess for tactile fremitus
✕Assess for muffled heart sounds
✕Inspect the chest for lag on the affected side
Potential Conditions
✓Lobar pneumonia
✕Pleural effusion
✕Atelectasis
✕Acute bronchitis
Parameters to Monitor
✓Respiratory rate and pulse
✕Cyanosis
✕Wheezing
✓Crackles
✕Loud bronchial breathing
A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes. Exhibits A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.
(SATA)
A)
Small joints of the hand
B)
Joint swelling
C)
Symmetrical involvement
D)
Pain increases with motion
E)
Heberden nodes
F)
Fatigue and fever
G)
Morning stiffness quickly resolves
A nurse is caring for a 73-year-old male client in an assisted living facility. The client has a history of a left-sided stroke and is experiencing increasing weakness and a decrease in range of motion (ROM) on the right side. The nurse begins the assessment at 0700hrs. Exhibits Based on the exhibits provided, what type of range of motion was being assessed for each joint? Select one response per row.
Abduction Flexion Extension
Elbow ✓
Wrist ✓
Shoulder ✓

	Abduction	Flexion	Extension
Elbow			✓
Wrist		✓
Shoulder	✓

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Exam Review

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition. Exhibits A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?
A)
Administer the prescribed morphine sulfate.
B)
Prepare the cast cart for immobilization.
C)
Perform a neurovascular assessment of the right hand.
D)
Initiate the IV infusion of 0.9% sodium chlorid
When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?
A)
Works in a day care center.
B)
Adheres to a gluten-free diet.
C)
Takes an oral anticoagulant.
D)
Recently had dental surgery.
When evaluating a client’s rectal bleeding, which findings should the nurse document?
A)
Number of blood clots expelled with each stool.
B)
Unique odor noted with gastrointestinal bleeding.
C)
Color characteristics of each stool.
D)
Evidence of internal hemorrhoids.
Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?
A)
Sorting a collection of socks.
B)
Opening a bar soap package.
C)
Telephoning a family member.
D)
Reading a short paragraph.

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Exam Review

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?
A)
Ask the client to describe any other related symptoms.
B)
Place the dorsum of the hand on the client’s forehead.
C)
Use both hands to hold and palpate the client’s hands.
D)
Lightly pinch a fold of skin over the client’s sternum.
While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?
A)
Painful symptoms alleviated by warmth.
B)
Cool, pale skin below the knees.
C)
Decreased pain when legs are elevated.
D)
Deep, continuous pain in the calf muscles.
To assess a client’s pupillary reaction to accommodation, which action should the nurse take?
A)
Observe pupil size when focusing on a near object and then a far object.
B)
Determine if dilation of the pupils occurs when the room is darkened.
C)
Note the speed of pupil constriction when a penlight is shined into the eye.
D)
Compare the shape of each of the pupils bilaterally with normal room light.
While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?
A)
Benign variation.
B)
Cardiac enlargement.
C)
Cardiac atrophy.
D)
Expected finding.

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Exam Review

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?
A)
Give the client 8 ounces (236.5 mL) of water to drink.
B)
Send the sample for laboratory evaluation.
C)
Instruct the client to attempt to urinate again.
D)
Evaluate the client for bladder distention.
While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?
A)
Begin to orient the client to her surroundings in the hospital room.
B)
Stand directly in front of the client and ask about any hearing loss.
C)
Obtain a tuning fork to complete Rinne and Weber tuning fork tests.
D)
Perform a mental status exam to assess the client’s thought processes.
The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?
A)
Audible thud without pain.
B)
Sharp, severe pain.
C)
Rebound tenderness.
D)
Rigidity and firmness.
The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?
A)
Impaired memory.
B)
Impaired thinking.
C)
Normal mental status for age.
D)
Impaired concentration.

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Exam Review

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?
A)
Translucent, pearly gray and mobile tympanic membrane.
B)
Red, edematous ear canal with no visualization of the tympanic membrane.
C)
Thickened and bulging tympanic membrane.
D)
Retracted and non-mobile tympanic membrane.
The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?
A)
Tenderness.
B)
Thrill.
C)
Non-tender.
D)
Crepitus.
While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?
A)
Hypotonic tone of the anal sphincter.
B)
Dimpled area above anus.
C)
Increased pigmentation and coarse skin.
D)
Flap of tissue at sphincter.
The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?
A)
A 75-year-old with a pneumothorax and a chest tube.
B)
A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg).
C)
A 2-year-old who is demonstrating diaphragmatic breathing.
D)
A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m².

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Exam Review

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?
A)
Diabetes mellitus.
B)
Iron deficiency anemia.
C)
Coronary heart disease.
D)
Recent candida infection.
Which assessment finding supports the client statement, “My feet swell all the time?”
A)
Positive Homan’s sign bilaterally.
B)
2+ pitting edema of ankles bilaterally.
C)
Pedal pulses weak and thready.
D)
Capillary refill in both feet greater than 3 seconds.
During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen.Which action should the nurse take in response to this observation?
A)
Palpate the area for masses.
B)
Observe the midline for scarring.
C)
Ask about recent abdominal trauma.
D)
Document the normal finding.
An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client’s skin for which finding?
A)
Fissuring.
B)
Excoriation.
C)
Papules.
D)
Wheals.

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