A nurse performing assessments knows it would be most important to assess
vital signs when a client:
is coughing and sneezing.
finishes ambulating in the hallway.
sits on the side of the bed after surgery for the first time.
complains of pressure in the chest. - ANSWER complains of pressure in the
chest.
Which of the following assessments is NOT included in inspection of the
nails?
shape of the nails
,fullness of the nails
color of the nails
angle of the nails - ANSWER fullness of the nails
To assess pulse deficit of an adult client, the nurse taking the apical pulse
plans to:
place the stethoscope at the client's third intercostal space.
ask another nurse to assist with the procedure.
ask the client to take a deep breath.
place the client in a side-lying position. - ANSWER ask another nurse to assist
with the procedure.
The nurse is assessing the apical pulse on a male client. Which of the
following actions would indicate a need for further instruction about the
technique?
Warms the diaphragm of the stethoscope.
Tells the client, 'I am listening to your heart.'
Assures that the patient is in a lying or sitting position.
Places the stethoscope on the right side of the chest wall. - ANSWER Places
the stethoscope on the right side of the chest wall.
The nurse is preparing a client for an endoscopy. Which of the following is a
nurse's responsibility for diagnostic procedures and tests?
delegating care during the procedure to others
, writing the order for the procedure
providing emotional and physical preparation
ensuring the results of the diagnostic test are recorded - ANSWER providing
emotional and physical preparation
The adult client reports pain on the outside of the left ear. The nurse's next
action would be which of the following?
Perform a Weber and Rinne test.
Inspect and gently palpate the pinna.
Ask the client if they have been exposed to loud noises recently.
Pull down gently on the tragus to visualize the external auditory canal. -
ANSWER Inspect and gently palpate the pinna.
Which of the following statements is true about acute pain?
lasts beyond the normal healing period
poorly localized
is intermittent
rapid in onset and protective in nature - ANSWER rapid in onset and
protective in nature
A client diagnosed with hypertension asks the nurse about blood pressure
monitoring equipment for home use. The nurse should instruct the client
that:
digital blood pressure monitoring equipment is not very accurate.
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