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NUR 256 - Exam 1 QUESTIONS AND
VERIFIED ANSWERS 100% CORRECT
A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication which of the following actions demonstrates the use of a nonverbal communication technique by the nurse A. asking the client to clarify a statement B. asking the client open-ended questions C. maintain a fair distance between self and client D. stating the name and providing credentials upon entering the client's room
- ANSWER>>maintain a fair distance between self and client A nurse is preparing to irrigate a client's leg wound what PPE should the nurse wear? surgical cap gown goggles gloves N95 mask
- ANSWER>>Goggles, gown, gloves A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states " I have changed my mind; Ido not want to have this surgery" which of the following ethical principles is the client using? A. Nonmaleficence B. Autonomy
C. Justice D. Fidelity
- ANSWER>>Autonomy A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy? A. Close the examination room door but do not pull the curtain in the examination room B. Remain in the client's room while the client is getting undressed C. Ask the client if they would like to empty their bladder or bowels before the physical examination begins D. Do not expose any more of the client's body than required at a time
- ANSWER>>Do not expose any more of the client's body than required at a time A nurse is assisting a client with ambulating around the nurses' station. which of the following steps of the nursing process is the nurse performing? A. Implementation B. Evaluation C. Analysis D. Planning
- ANSWER>>Implementation A nurse is performing an assessment on a client the client states "I have a dry cough every morning when I wake up" which of the following is the type of date the nurse is collecting? A. Subjective
A. Tongue Depressor B. Penlight C. Reflex hammer D. Stethoscope
- ANSWER>>Stethoscope A nurse in the emergency department has received report on a child who has a laceration to the right calf which of the following steps of the nursing process should the nurse perform first? A. Assessment B. Analysis C. Evaluation D. Planning
- ANSWER>>Assessment A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation? A. Unexpected sounds made by tapping on the client's skin B. Skin temperature, moisture, or unexpected findings C. Heart sounds, lunch sounds, and bowel sounds D. The client's cleanliness and grooming
- ANSWER>>Skin temperature, moisture, or unexpected findings A nurse is performing a physical assessment of a client who has reported abdominal tenderness which of the following actions should the nurse take?
A. Use the soft end of a cotton swab over the client's abdomen B. Auscultate the tender areas of the client's abdomen through clothing C. Palpate the tender areas of the client's abdomen last D. Use deep palpation when assessing the client's abdomen
- ANSWER>>Palpate the tender areas of the client's abdomen last A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant which of the following is the first step the nurse should perform during the abdominal assessment? A. Palpation B. Percussion C. Auscultation D. Inspection
- ANSWER>>Inspection A nurse is completing documentation in a client's medical record. Which of the following entries display proper documentation by the nurse? A. The client is feeling better B. The client's abdomen is soft and distended C. The client's status is unchanged D. The client appears in pain
- ANSWER>>The client's abdomen is soft and distended
A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information did the nurse collect during the general survey? Height and weight Use of assistive devices Behavior and mood Past medical history Current medication list - ANSWER>>Height and weight Use of assistive device Behavior and mood A nurse is caring for a client who is comatose. Which of the following alternative routes should the nurse use to obtain the most accurate core temp of the client? A. Axillary B. Temporal C. Tympanic D. Rectal - ANSWER>>Rectal A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? Take the client's BP in the supine position Keep the cuff in place and assist the client to a seated position Assist the client to stand and then obtain their BP Place the client in a supine position and allow them to rest Take the client's BP in a seated position - ANSWER>>Place the client in a supine position and allow them to rest. Take the client's BP in supine position Keep the cuff in place and assist the client to a seated position.
Take the client's BP in a seated position. Assist the client to stand and obtain their BP. A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? A. Deduct the client's shoe height from the measurement B. Have the client gently life their chin and look toward the ceiling C. Ensure the client's feet are in contact with the wall or measuring pole D. Pull up the measuring pole and extend the headpiece after the client steps on the scale - ANSWER>>Ensure the client's feet are in contact with the wall or measuring pole A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? A. Have an informal conversation with the client before beginning the observation of the client B. Complete all focused assessments prior to formulating thoughts regarding the client's general health status C. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible D. Engage in active listening with the client and allow the client to express concerns early in the assessment process - ANSWER>>Engage in active listening with the client and allow the client to express concerns early in the assessment process A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate? A. The client has been a chronic smoker for 10 years B. The client takes a narcotic pain medication for chronic pain C. The client reports anxiety due to being in a hospital D. The client has a history of anemia - ANSWER>>The client takes a narcotic pain medication for chronic pain
"The pain has been off and on for about a year now" "The pain isn't always in the same place" "I still have pain since the surgery last month, but it is getting better" "I have had this pain for 9 months" - ANSWER>>"I have had this pain for 9 months" "The pain isn't always in the same place" "The pain has been off and on for about a year now" A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? A. Bradycardia B. Tachycardia C. Fasciculation D. Tachypnea - ANSWER>>Tachycardia A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe the involuntary movement? A. Fasciculation B. Spasticity C. Tic D. Myoclonus - ANSWER>>Fasciculation A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following info should the nurse include as factors that affect BP? Smoking Time of day Obesity
Height Diuretic medication - ANSWER>>Time of day, obesity, diuretic medicine, and Smoking A nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing. This is an example of what type of question? A. leading question B. closed ended question C. direct question D. open ended question - ANSWER>>Open ended question A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation? A. "I had a rash from poison ivy on my arms last week, but it's gone now" B. "I wear a hearing aid" C. "I had a negative tuberculosis screening test last month" D. "I have a cough" - ANSWER>>"I have a cough" A nurse is planning to conduct a health history interview with a client. which of the following actions should the nurse plan to take? (select all that apply) A. gather supplies to take notes B. review the client's medical record at the conclusion of the interview C. conduct the interview in an open area such as the receptions area or hallway D. select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview E. ensure a face to face contact is at eye level - ANSWER>>Gather supplies to take notes Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview Ensure a face to face contact is at eye level
C. "when did you transition?" D. "Are you planning to ever have surgery to change your biological sex?" - ANSWER>>"What pronouns do you use?" A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health? A. limited access to convenience foods B. a park available within walking distance from a client's residence C. limited access to a pharmacy D. a neighborhood population that has a high rate of obesity & smoking - ANSWER>>Limited access to a pharmacy A nurse is conducting a health history interview with a client. which of the following is accurate about a directive interview technique? A. this technique consists of mostly closed ended questions B. this technique enables the client to control the pace of the interview C. This technique is used to gather general information about a client's condition D. this technique is effective for determining a client's emotional responses - ANSWER>>This technique consists of mostly closed ended questions A nurse is preparing to conduct a health history interview. Which of the following actions should the nurse plan to perform during the closing stage of the interview? A. document client data B. provide an opportunity for client to ask questions C. explain the reason for the insurance D. greet client with an introduction - ANSWER>>Provide an opportunity for client to ask questions
A nurse is collecting a healthy history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take? A. speak directly to the client throughout the interview B. ensure the interpreter is positioned behind the client for privacy C. ask the interpreter to summarize a group of questions for the client D use accurate medical terminology when gathering information - ANSWER>>Speak directly to the client throughout the interview A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take? A. asses the client's blood glucose level B. ask the client for additional information regarding the management of their diabetes C. encourage the client to join a diabetic support group D. provide education for the client on the management of diabetes - ANSWER>>Ask the client for additional information regarding the management of their diabetes A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (select all that apply) A. prescription medications taken for recreational purposes B. determination of when the client last had an alcoholic drink C. frequency of consumption of over the counter(OTC) medications D. adverse reactions to medications & environmental substances E. highest level of schooling completed - ANSWER>>Prescription medications taken for recreational purposes Determination of when the client last had an alcoholic drink
C. Information about the client's obstetrical history D. Information about the client's family history - ANSWER>>Information about the clients presenting problem A nurse is performing a head-to-toe assessment of a client. Which of the following findings indicate the client might be experiencing respiratory difficulty? (Select all that apply.) A. The client occasionally sighs B. The client is sitting in a tripod position C. The client's respiratory rate is 18/min D. The client is using pursed lipped breathing E. The client appears confused - ANSWER>>The client is sitting in a tripod position The client is using pursed lipped breathing The client appears confused A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? A. The nurse asks the client to cough before the auscultation B. The nurse is auscultating through the client's gown C. The nurse places the stethoscope on the intercostal spaces D. The nurse moves down the chest in a ladder sequence - ANSWER>>The nurse is auscultating through the client's gown A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (Select all that apply.) A. Numbness and tingling of extremities
B. Decreased chest wall expansion C. Lightheadedness D. Periods of apnea E. Chest pain - ANSWER>>Numbness and tingling of extremities Lightheadedness Chest pain A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A. Instruct the client to deep breathe and cough B. Provide the client with an incentive spirometer C. Elevate the head of the bead D. Reassess by auscultating the client's lungs - ANSWER>>Elevate the head of the client's bed A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing? A. Thoracic breathing B. Cheyne-Stokes breathing C. Bradypnea D. Kussmaul breathing - ANSWER>>Cheyne-Stokes breathing A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make? A. "It's just a small number of people that get the flu from receiving the vaccine" B. "Call your provider immediately if you have flu-like symptoms after receiving the vaccine"
A. I cannot sleep at night because I get short of breath B. Client seems to not like certain staff members C. Client's partner does not visit the client enough D. Inspiratory wheeze auscultated at left lateral chest - ANSWER>>Inspiratory wheeze auscultated at left lateral chest A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor-vehicle crash. Which of the following findings is an indication of a pneumothorax? A. The client's ribs slope downward at a 45 degree angle B. The client is making a high-pitched crowing sound that can be heard in the neck area C. The diameter of the chest appears barrel-like with horizontal ribs D. The client is experiencing unequal movement of the posterior chest - ANSWER>>The client is experiencing unequal movement of the posterior chest A nurse is preparing to auscultate a client's posterior and lateral chest. In which order should the nurse perform the following actions? Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location Auscultate the lateral sides slightly below the axillary area Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine Expose the posterior chest with the client sitting with their arms folded across their chest is the first step
- ANSWER>>Expose the posterior chest with the client sitting with their arms folded across their chest Auscultate 8 cm (3 in) to one side of the spine around C7, then auscultate the other side of the spine in the same location
Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine Auscultate the lateral sides slightly below the axillary area, then down to the seventh or eighth rib A nurse is assessing a client who is dark-skinned. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (Select all that apply.) A. Cheeks B. Nail beds C. Oral mucosa D. Sclerae E. Nasal cavity - ANSWER>>Nail beds Oral mucosa A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (Select all that apply.) A. Coarse grating tone B. Intermittent popping or bubbling sound C. Heard on inspiration and expiration D. Snoring sound on expiration E. Pain with breathing - ANSWER>>Coarse grating tone Heard on inspiration and expiration Pain with breathing
