Deck 52: Assessment

Question 1

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

A)Temperature
B)Apical pulse
C)Respiratory rate
D)Pain using a pain scale

Answer 1

Apical pulse

Question 2

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?

A)"Give your mom time, because it will take her a little longer when answering questions."
B)"Let me check the cranial nerve function to see if there is a defect in her mental status."
C)"You do not need to worry. This decline is part of the normal process of aging."
D)"If you bring some things from her home, it might reduce the confusion."

Answer 2

"If you bring some things from her home, it might reduce the confusion."

Question 3

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

A)There is no pubic hair except for fine body hair.
B)Pubic hair is developing along the labia.
C)Pubic hair distribution extends to umbilicus.
D)Pubic hair appears on the inner aspect of the thigh.

Answer 3

Pubic hair appears on the inner aspect of the thigh.

Question 4

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?

A)"I might hear a friction rub with a cold stethoscope."
B)"A nice nurse will put a warm stethoscope on your abdomen."
C)"A cold stethoscope may cause your abdominal muscles to contract."
D)"Warming up the stethoscope will help with the digestion of your food."

Question 5

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

A)15 seconds
B)30 seconds
C)1 minute
D)2 minutes

Question 6

Based on the information provided, which client should the nurse see first?

A)Infant respirations 38/min
B)2-year-old pulse 112/min
C)6-year-old axillary temperature 97.5°F
D)10-year-old blood pressure 138/88

Question 7

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?

A)Oral
B)Rectal
C)Axillary
D)Tympanic membrane

Question 8

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?

A)Chest x-ray
B)Pulse oximeter
C)Arterial blood gasses
D)Assessment of respiratory rate

Question 9

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

A)Oral
B)Rectal
C)Axillary
D)Tympanic
E)Heat sensitive

Question 10

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?

A)Encourage the client to cough and deep breathe.
B)Notify the healthcare provider of abnormal breath sounds.
C)Document assessment findings as normal breath sounds.
D)Raise the head of the bed to allow maximum air excursion.

Question 11

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

A)Wrap the tape measure around the head below the ears.
B)Wrap the tape measure around the head starting at the nose.
C)Wrap the tape measure around the abdomen at the umbilicus.
D)Wrap the tape measure around the chest below the nipple line.

Question 12

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

A)"Do you exercise every day?"
B)"Do you have a history of any sports injuries?"
C)"Do you take a hot bath to relax your muscles?"
D)"Do you want pain medication before I begin?"

Question 13

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

A)Oral
B)Rectal
C)Scanner
D)Tympanic

Question 14

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

A)Weight gain
B)Rectal bleeding
C)Unusual cough
D)Change in bowel function
E)Decrease medication absorption

Question 15

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

A)Bladder to cuff ratio too wide
B)Arm unsupported
C)Cuff wrapped too loosely
D)Arm below heart level

Question 16

Before completing a blood pressure on an adult, which should the nurse do next after introducing self?

A)Provide privacy.
B)Perform handwashing.
C)Identify the client with two identifiers.
D)Explain what he or she will be doing with the client.

Question 17

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

A)Call the health care provider.
B)Administer pain medication.
C)Reassess a new set of vital signs.
D)Turn client from supine to lateral.

Question 18

The UAP notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and BP 98/72. Which is the best action the nurse should do next?

A)Ask the UAP to reassess the client.
B)Inform the UAP to document these vital signs.
C)Reassess the client to validate these vital signs.
D)Notify the healthcare provider of these vital signs.

Question 19

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

A)Pull the pinna up and back.
B)Pull the pinna up and forward.
C)Pull the pinna down and back.
D)Pull the pinna down and forward.

Question 20

Which does the nurse observe for an adult client who has a negative Babinski response?

A)All toes turn inward.
B)All toes curve upward.
C)All toes spread outward.
D)All toes bend downward.

Question 21

Which task can the nurse delegate to the UAP?

A)Administration of medication
B)Recording findings from a sponge bath
C)Teaching a client how to take own vital signs
D)Assessing a client in the medical-surgical unit for two days

Question 22

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

A)Pain level
B)Respirations
C)Temperature
D)Blood pressure

Question 23

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

A)Kussmaul respirations
B)Blood glucose of 144
C)Pain level 6 out of 10
D)Temperature is 101.8°F

Question 24

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

A)"I will clean the site after applying the sensor."
B)"I will move the adhesive toe or finger sensor once a shift."
C)"I will remove any fingernail polish when using a pulse oximeter."
D)"I will use the side of the finger rather than perpendicular to the nail bed."