Download Nursing Assessments: Identifying Client Understanding and Required Precautions and more Exams Nursing in PDF only on Docsity!
ASSESSMENT 1 PRE PROCTORIO
FUNDAMENTALS (NURS 100)
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? - ans"It might help me to listen to music while I'm lying in bed." (Listening to music is an effective nonpharmacological intervention for the management of mild pain.) A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - ans-obtain the death pronouncement from the provider -remove tubes and indwelling lines -wash the client's body -ask the family members if they wish to view the body place a name tag on the body A nurse in a provider's clinic is caring for a client who has diarrhea. -Exhibit 1 Vital Signs Temperature 36.2° C (97.2° F) Pulse rate 116/min Respiratory rate 24/min BP 102/68 mm Hg Oxygen saturation 95% Weight 52.2 kg (115 lb) -Exhibit 2 Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100:
Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching - ansThe nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. -Eat probiotic foods, such as yogurt. -Avoid alcohol while experiencing diarrhea. -Avoid caffeine while experiencing diarrhea. -Follow a low-fiber diet. A nurse in a provider's clinic is caring for a client who has heart failure. -Exhibit 1 Nurses' Notes First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following - ansA nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? -"I am limiting my sodium intake to 2 grams daily." -"I am eating fewer potato chips and more fruit for snacks." -"I know to call my doctor if I gain 3 pounds or more in 2 days." A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? - ans* IMAGE OF NURSE HITTING THE KNEE** The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer. A nurse in an emergency department is caring for a client. -Exhibit 1 Physical Examination 1200: Influenza with nausea, vomiting, and diarrhea for 3 days.Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria.Plan: Admit for IV fluids. -Exhibit 2
-Exhibit 2 Vital Signs 1100: BP 138/72 mm Hg Heart rate 80/min Respirations 22/min Temperature 38.3° C (101.1° F) Oxygen saturation 90% on room air -Exhibit 3 Diagnostic Results 1400: Chest x-ray positive for inflammation and infiltrates in upper lobes QuantiFERON-TB positive (negative) Tuberculosis culture positive (negative) - ans*Wear an N95 mask when caring for the client *Place a container for soiled linens inside the client's room *Place the client in a negative airflow room *Remove mask after exiting the client's room -Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. -Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. -Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. -Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? - ansContact precautions (Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.) A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? - ansDuring the admission process (Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.)
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? - ansCompare the client's home medications with the provider's prescriptions. (The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.) A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? - ans"Is your pain sharp or dull?" (Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.) A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) - ansPupil clarity Visual fields Visual acuity -Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. -Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. -Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall. A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? - ansEnsure the bladder of the blood pressure cuff surrounds 80% of the client's arm. (The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.) A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) Crackles Rhonchi Friction rub Normal breath sounds - ansNormal breath sounds
Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. - ansThe nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. -Stop the IV infusion. -Elevate the client's left arm. -Apply heat to the client's left hand. (*Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. *Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. *Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.) A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? - ansTurn the client every 2 hr. (The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.) A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? - ans"I am relying on support from our family during this time." (This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.) A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? - ans"I am available to talk if you should change your mind." (When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client.) A nurse is caring for a client who has COPD. -Exhibit 1 Nurses' Notes 1000:
Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. -Exhibit 2 Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air -Exhibit 3 Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. - ansSelect the 3 findings that require follow-up -Breath sounds -Oxygen saturation -Temperature (1.-Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. 2.-Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. 3.-Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.) A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? - ansUse a bed exit alarm system. (The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.) A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? - ansAcupuncture (The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.) A nurse is caring for a client who has pancreatitis. -Exhibit 1 Nurses' Notes
BP 125/65 mm Hg Temperature 39.2° C (102.6° F) Oxygen saturation 95% 1200: Heart rate 94/min Respirations 18/min BP 115/65 mm Hg Temperature 37.8° C (100° F) Oxygen saturation 96% -Exhibit 2 Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough -Exhibit 3 Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Puls - ansComplete the following sentence by using the list of options. The nurse should identify that the client might be experiencing Extravasation as evidenced by the client's IV catheter site. (Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation.) A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? - ansReassure the client that this is an expected response to grief. (During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.) A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? - ansNotify the nursing manager. (The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.)
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? - ansDetermine the reasons why the client is refusing to use the incentive spirometer. (The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.) A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? - ansMake sure two fingers can fit under the sleeves. (The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.) A nurse is caring for a client who is postoperative following abdominal surgery. -Exhibit 1 Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. - ansClick to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. -Urinary output -Reported pain level -Vital signs A nurse is caring for a client who is receiving a unit of packed RBCs. -Exhibit 1 Nurses' Notes 0800:Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815:Client reports itching and anxiety. Client's face is flushed and has hives.
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? - ansStand close to the cabinet when lifting it. (This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.) A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? - ansThe client identifies the location of a fire extinguisher. (The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.) A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? - ansA mole with an asymmetrical appearance (An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.) A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? - ansUse the planning step of the nursing process to prioritize client care delivery. (Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.) A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? - ansPlace the client's arm in a dependent position. (The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.) A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? - ansSituation, background, assessment, and recommendation (SBAR) (SBAR is a communication tool nurses use to relate a client's status during a change-of- shift report.) A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? - ansAdvocacy ensures clients' safety, health, and rights. (Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.) A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer
to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- ansX mL/hr= 750 mL / 7 hr= 107 answer 107 (rounded to nearest whole #) A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? - ansAsk another nurse to observe the medication wastage. (A second nurse must witness the disposal of any portion of a dose of a controlled substance.) A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? - ansAdminister the medication with the needle at a 45° angle. (The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.) A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? - ansHydrocolloid (Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.) A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? - ans"I will hire someone to trim the tree that hangs low over the stairs of my front porch." (Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.) A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? - ansAdminister the medication into the abdomen. (The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.) A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? - ansCheck the client for injuries. (The first action the nurse should take when using the nursing process is to assess the client for injuries.) A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? - ansPotassium 5.4 mEq/L (This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.) A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? - ansRegulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
