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(NURS 100) Assessment 2. WCU questions and answers rated A+ 2024/2025
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(NURS 100) Assessment 2. WCU questions and answers rated A+ 2024/2025
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(NURS 100) Assessment 2. WCUC. The top side rail is raised contrary the facet in which the nurse is standing.
D. The mattress is always saved in a flat role with a pillow under the affected person's head. -
ANS-c. The pinnacle side rail is raised contrary the side wherein the nurse is status.
The mattress is raised to a comfortable operating role and the side rail is diminished at the side
wherein the nurse is standing. It is essential to depart the mattress in the low and locked
function with the top side rails up while the tub is finished and the nurse is leaving the room. The
position of the bed and the patient all through the tub is depending on the patient's situation and
comfort degree.
LO: 27.6
DIF: Applying
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control
A rate nurse is staring at a nurse auscultating a client's bowel sounds. Which of the subsequent
moves calls for intervention? - ANS-Palpate the stomach previous to performing auscultation
A home fitness nurse is conducting a home safety evaluation for an older person client. Which
of the subsequent findings must the nurse perceive as a safety chance for the customer? -
ANS-Water temp (^120) Throw rugs
A newly certified nurse is applying prescribed wrist restraints on a purchaser. Which of the
subsequent...? - ANS-Secure the restraints the use of a brief-launch tie.
A nurse assesses a client who has a wrist restraint carried out. For which of the following
findings have to the nurse loosen the restraints? - ANS-The customer's hand is cool and light.
A nurse at a clinic is gathering facts about ache from of a purchaser who reviews excessive
stomach pain. The nurse asks the client whether or not he has nausea and has been vomiting.
Which of the following ache traits is the nurse attempting to determine?
A.Presence of associated manifestations
B.Location of the pain
C.Pain pleasant
D. Tense and relieving factors - ANS-A
A. The nurse ought to attempt to perceive manifestations that occur in conjunction with the
customers ache, together with nausea, fatigue or anxiety.
A nurse at an prolonged-care facility is educating a category of AP approximately consumer use
of assistive devices all through ambulation. Which of the subsequent commands... About using
a cane? - ANS-When the patron actions, he have to pass the cane forward first
A nurse if assessing a patron's bowel sounds. At which of the subsequent points inside the
assessment ought to the nurse auscultate the customer's stomach? - ANS-Prior to percussing
the stomach
,A nurse in a medical institution is assessing a consumer. Which of the subsequent findings need
to the nurse pick out as a danger issue for osteoporosis?
A. Drinks one alcoholic beverage consistent with day
B. Smokes 1 % of cigarettes in keeping with day
C. Large body stature
D. History of bone fracture at some point of youth - ANS-B. Smokes 1 % of cigarettes in keeping
with day
A nurse in a health center is being concerned for an older adult customer who reports dry, flaky
pores and skin on her upper lower back/ which of the following is an intervention? - ANS-Pinch
up a fold of pores and skin to test for turgor
A nurse in a health center is speaking with a consumer who has a new analysis of osteoarthritis.
The nurse need to count on that the client would require teaching about which of the following
medicinal drugs?
A. Acetaminophen
B. Celecoxib
C. Cyclobenzaprine
D. Ibuprofen - ANS-A. Acetaminophen
A nurse in a family exercise clinic is appearing a bodily exam of an adult customer. Which a part
of her arms ought to she use for the duration of palpation for most fulfilling assessment of skin
temperature?
A.Palmar surface
B.Fingertips
C.Dorsal floor
D.Base of the arms - ANS-C
C. The dorsal floor of the hand is the maximum sensitive to temperature.
A nurse in a long time care facility enters the day room and finds the window curtains on hearth.
Clients are panicking and the room is filling with smoke. Indicate the emergency movements the
nurse have to take. - ANS-REMOVE
ACTIVE
CLOSE THE DOOR
EXTINGUISH THE FIRE
A nurse in a scientific medical institution is supplying teaching to an older person consumer who
has osteoarthritis that is affecting her knees. Which of the subsequent patron statements
indicated an information of the coaching?
A. "I can use either heat or ice to assist relieve the discomfort."
B. "Ibuprofen is the first step in medication remedy for osteoarthritis."
C. "I must restrict bodily activity to prevent similarly damage."
D. "I will increase my legs with the aid of placing two pillows beneath my knees when I go to
bed. - ANS-A. "I can use both heat or ice to help relieve the pain."
, A nurse in a company's office is gathering a fitness records from a purchaser who is at hazard
for primary osteoporosis. Which of the following findings is a risk factor for the development of
osteoporosis?
A. Obesity
B. Sedentary way of life
C. Long-time period use of diuretics
D. Prolonged strain - ANS-B. Sedentary lifestyle
A nurse in a provider's workplace is documenting his findings following an examination he
accomplished for a customer new to the practice. Which of the subsequent parameters have to
he encompass as part of the general survey? (Select all that apply.)
A. Posture
B. Skin lesions
C. Speech
D. Allergies.
E. Immunization status - ANS-A, B, C
A. Posture is part of the body structure or popular look part of the general survey.
B. Skin lesions are a part of the frame shape or general appearance part of the general survey.
C. Speech is a part of the behavior portion of the overall survey
A nurse in a provider's office is making ready to evaluate a young person male purchaser's
musculoskeletal gadget as part of a comprehensive bodily examination. Which of the
subsequent findings must the nurse assume? (pick out all that observe.)
A. Concave thoracic backbone posteriorly
B. Exaggerated lumbar curvature
C. Concave lumbar spine posteriorly
D. Exaggerated thoracic curvature
E. Muscles slightly large on his dominant aspect - ANS-C,E
C. The nurse have to expect the patron to have a concave lumbar backbone posteriorly.
E. The nurse need to assume the customer to have muscle size equal on each facets or barely
large at the dominant side.
A nurse is assessing a patron following the application of a leg solid for the remedy of a fracture.
If the forged is simply too tight, which of the following findings have to the nurse count on to
observe first?
A. Change in temperature of the ft.
B. Pallor of the toes.
C. Edema of the toes.
D. Inability to move toes. - ANS-B. Pallor of the ft.
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