Exam 52: Assessment

Which is the best route to check a temperature for a client who is diaphoretic? Select all that apply.

When measuring the newborn during a general assessment, which is the correct assessment?

A client's daughter mentions to the nurse that her mom seems to have a decline in mental status and seems to be forgetting many things in their conversation since this hospitalization. Which is the best response by the nurse?

Prior to administering digoxin, which should the nurse assess first?

Which does the nurse observe during the assessment while documenting a Tanner Stage 5?

A client on the medical/surgical unit complains of sudden chest pains. Which is the first action the nurse will implement?

Which statement made by the UAP is best in understanding the teaching from the nurse?

Which would cause an erroneously low blood pressure during a general assessment for an adult client?

The nurse is completing an assessment on a client who just received morphine. Which is the nurse's highest priority?

A new client came to the clinic complaining of shortness of breath and fever. How long should the triage nurse count the peripheral pulse?

The nurse is changing a 2-month-old client's diaper and notes the client feels warm to touch. Which is the best method for checking this baby's temperature?

After receiving shift report, which of the following clients should the nurse assess first?

The nurse is observing the UAP taking the temperature of an unconscious client. Which route will the nurse question the UAP using?

Which is the appropriate way to hold the ear when inspecting the tympanic membrane of a 2-year-old client?

Which is the best response by the nurse when explaining to the client as to why the stethoscope is warmed up before placing it on the abdomen?

Which is the most important question the nurse should ask a client before performing a routine musculoskeletal assessment?

Which are signs and symptoms of colon cancer? Select all that apply.

Which task can the nurse delegate to the UAP?

A client comes in with exacerbation of chronic obstructive pulmonary disease (COPD). Which noninvasive diagnostic test will the nurse implement to know that the client is receiving enough oxygen?

The nurse coming on duty received in report that the client's lung sounds were clear to auscultation in all lobes. The nurse coming on heard moderate-intensity and moderate-pitch "blowing" sounds between the scapulae and lateral to the sternum at the first and second intercostal spaces when doing her own assessment. Which should the nurse do next?