Question 1

The nurse is aware that the best way to assess dependent pitting edema in a patient with congestive heart failure is to:

Accepted Answer

A)  measure the circumference of the ankles daily. 
B)  inquire whether the patient's shoes fit tightly. 
C)  auscultate lung sounds every shift. 
D)  press fingers into the tissue over the tibia, just above the ankle. 
A)  measure the circumference of the ankles daily. 
B)  inquire whether the patient's shoes fit tightly. 
C)  auscultate lung sounds every shift. 
D)  press fingers into the tissue over the tibia, just above the ankle.

Question 2

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Accepted Answer

A)  admission to the unit. 
B)  discharge. 
C)  the beginning of each shift. 
D)  the patient's wakening in the morning. 
A)  admission to the unit. 
B)  discharge. 
C)  the beginning of each shift. 
D)  the patient's wakening in the morning.

Question 3

The nurse weighing an infant in an outpatient clinic should:

Accepted Answer

A)  place a towel on the scale prior to weighing the baby. 
B)  place the baby in a prone position on the scale to reduce the infant's movement. 
C)  keep one hand hovering over the infant during the weighing procedure. 
D)  rest a hand lightly on the infant's abdomen during weighing to prevent a fall. 
A)  place a towel on the scale prior to weighing the baby. 
B)  place the baby in a prone position on the scale to reduce the infant's movement. 
C)  keep one hand hovering over the infant during the weighing procedure. 
D)  rest a hand lightly on the infant's abdomen during weighing to prevent a fall.

Question 4

The nurse is aware that the most accurate quick method to check hydration status in the older adult is to evaluate the moisture of the ______.

Accepted Answer

mucous membranes
The loss of s

Question 5

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

Accepted Answer

A)  psychological history. 
B)  financial history. 
C)  cultural assessment. 
D)  literacy assessment. 
A)  psychological history. 
B)  financial history. 
C)  cultural assessment. 
D)  literacy assessment.

Question 6

A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Accepted Answer

A)  monitor for skin turgor every shift. 
B)  monitor peripheral pulses once a shift. 
C)  auscultate lung sounds at the beginning of a shift. 
D)  auscultate for bowel sounds once a shift. 
A)  monitor for skin turgor every shift. 
B)  monitor peripheral pulses once a shift. 
C)  auscultate lung sounds at the beginning of a shift. 
D)  auscultate for bowel sounds once a shift.

Question 7

The nurse uses the technique of inspection to initially assess: (Select all that apply.)

Accepted Answer

A)  skin tone. 
B)  skin turgor. 
C)  body contours. 
D)  color. 
E)  characteristics of movement. 
A)  skin tone. 
B)  skin turgor. 
C)  body contours. 
D)  color. 
E)  characteristics of movement.

Question 8

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Accepted Answer

A)  "You stand 50 feet away from the chart while I test each of your eyes." 
B)  "I will be testing your vision with your reading glasses on." 
C)  "You stand 20 feet away from the chart while I test each of your eyes." 
D)  "The number beside the largest print read is your visual acuity score." 
A)  "You stand 50 feet away from the chart while I test each of your eyes." 
B)  "I will be testing your vision with your reading glasses on." 
C)  "You stand 20 feet away from the chart while I test each of your eyes." 
D)  "The number beside the largest print read is your visual acuity score."

Question 9

A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

Accepted Answer

A)  "When I shine a light into the patient's eyes, the pupils should constrict." 
B)  "When I shine a light into the patient's eyes, the pupils should dilate." 
C)  "It is normal for the pupils to react sluggishly to light." 
D)  "Pupil checks should be performed with the room lights on." 
A)  "When I shine a light into the patient's eyes, the pupils should constrict." 
B)  "When I shine a light into the patient's eyes, the pupils should dilate." 
C)  "It is normal for the pupils to react sluggishly to light." 
D)  "Pupil checks should be performed with the room lights on."

Question 10

When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be placed on the:

Accepted Answer

A)  fifth intercostal space, left midclavicular line. 
B)  fifth intercostal space, left anterior axillary line. 
C)  second intercostal space, right midclavicular line. 
D)  fourth intercostal space, left lateral sternal border. 
A)  fifth intercostal space, left midclavicular line. 
B)  fifth intercostal space, left anterior axillary line. 
C)  second intercostal space, right midclavicular line. 
D)  fourth intercostal space, left lateral sternal border.

Question 11

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

Accepted Answer

A)  consensual reflex 
B)  brisk reflex. 
C)  accommodation. 
D)  dilation reflex. 
A)  consensual reflex 
B)  brisk reflex. 
C)  accommodation. 
D)  dilation reflex.

Question 12

Prior to assessing a patient's blood pressure in both arms, the nurse will instruct the patient to lie down for at least __________ minutes.

Accepted Answer

5
When blood pressure is measu

Question 13

The nurse assessing a patient's capillary refill finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to:

Accepted Answer

A)  assess the radial pulse and the blood pressure. 
B)  document the results as normal. 
C)  repeat the assessment. 
D)  notify the charge nurse. 
A)  assess the radial pulse and the blood pressure. 
B)  document the results as normal. 
C)  repeat the assessment. 
D)  notify the charge nurse.

Question 14

An 8-year-old patient is due for height measurement during a routine examination. For an accurate measurement to be obtained, the child should be asked to stand:

Accepted Answer

A)  with back toward the rod and the feet 6 inches apart. 
B)  with back toward the rod and the feet centered together. 
C)  with front toward the rod and the feet 8 inches apart. 
D)  with front toward the rod and the feet 4 inches apart. 
A)  with back toward the rod and the feet 6 inches apart. 
B)  with back toward the rod and the feet centered together. 
C)  with front toward the rod and the feet 8 inches apart. 
D)  with front toward the rod and the feet 4 inches apart.

Question 15

The nurse taking a blood pressure should:

Accepted Answer

A)  place the arm so that the brachial artery is at waist level. 
B)  position the patient so that the arm is level with the shoulder. 
C)  request that the patient put feet flat on the floor. 
D)  chat with the patient to reduce any anxiety in the patient. 
A)  place the arm so that the brachial artery is at waist level. 
B)  position the patient so that the arm is level with the shoulder. 
C)  request that the patient put feet flat on the floor. 
D)  chat with the patient to reduce any anxiety in the patient.

Question 16

Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of: (Select all that apply.)

Accepted Answer

A)  air. 
B)  infection. 
C)  fluid. 
D)  the inflammatory process. 
E)  a solid organ. 
A)  air. 
B)  infection. 
C)  fluid. 
D)  the inflammatory process. 
E)  a solid organ.

Exam 22: Assessing Health Status

The nurse is aware that the best way to assess dependent pitting edema in a patient with congestive heart failure is to:

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

The nurse weighing an infant in an outpatient clinic should:

The nurse is aware that the most accurate quick method to check hydration status in the older adult is to evaluate the moisture of the ______.

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

A nurse caring for a patient on bed rest with a history of respiratory health problems should:

The nurse uses the technique of inspection to initially assess: (Select all that apply.)

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?

When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be placed on the:

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

Prior to assessing a patient's blood pressure in both arms, the nurse will instruct the patient to lie down for at least __________ minutes.

The nurse assessing a patient's capillary refill finds that it took 5 seconds for the color to return. The most appropriate intervention to do following this assessment is to:

An 8-year-old patient is due for height measurement during a routine examination. For an accurate measurement to be obtained, the child should be asked to stand:

The nurse taking a blood pressure should:

Percussion is a technique by which the nurse can assess sounds relative to the underlying structures that indicate the presence of: (Select all that apply.)

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

The Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse Patient Relationship

Patient Education and Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, and End-of-Life Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Safe Lifting, Moving, and Positioning of Patients

Assisting with Hygiene Personal Care Skin Care and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Admitting Transferring and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid-Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Nutritional Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain Comfort and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Older Adult

Common Psychosocial Care Problems of Older Adults

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