A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use?
a. Prone
b. Sims'
c. Supine
d. Lateral recumbent
(Correct - c
A nurse is conducting Weber's test. Which action will the nurse ...
Fundamentals of Nursing Exam 1 : Questions & Answers A nurse is preparing to perform a complete physical examination on a weak, older -adult patient with bilateral basilar pneumonia. Which position will the nurse use? a. Prone b. Sims' c. Supine d. Lateral recumbent (Correct - c A nurse is conducting Weber's test. Which action will the nurse take? a. Place a vibrating tuning fork in the middle of patient's forehead . b. Place a vibrating tuning fork on the patient's mastoid process. c. Compare the number of seconds heard by bone versus air conduction. d. Compare the patient's degree of joint movement to the normal level. (Correct - a A head and neck physical examination is completed on a 50 -year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings? a. Oxygen saturation b. Liver function test c. Carbon monoxide d. Thyroid -stimulating hormone test (Correct - d Which is the most appropriate example of the assessment phase of the nursing process? Palpating a mass in the right lower quadrant of the abdomen Evaluating the temperature of a client given medication for a fever Documenting the administration of a medication provided for pain Including a nursing diagnosis of Acute Pain in the client's plan of care (Correct - Palpating a mass in the right lower quadrant of the abdomen The nurse understands that research has demonstrated that a common source of hospital -acquired infections in clients with IV infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Person -centered care Informatics Evidence -based practice Teamwork and collaboration (Correct - Evidence -based practice The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the most appropriate nursing action? Report it to the health care provider. Assess the client's back visually. Document it in the client's chart. Establish a nursing diagnosis of Altered Skin Integrity. (Correct - Assess the client's back visually A nurse technician is assigned to take client vital signs. When making rounds, the nurse notices that one client's vital signs are very different than they were at the beginning of the shift. What is most appropriate for the nurse to do about these finding s? Call the health care practitioner for new orders. Assess the client's vital signs again. Document the vital signs in the client's chart. Ask the nurse technician if the vital signs are correct. (Correct - Assess the client's vital signs again. A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? Administer an additional liter of intravenous fluids. Determine whether the prescribed treatment was effective. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor. (Correct - Determine whether the prescribed treatment was effective . The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? the inner and outer canthus of each eye underneath the fingernails and toenails underneath the breasts and in between skin folds the antecubital fossa and popliteal space (Correct - underneath the breasts and in between skin folds A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? client's allergies to soap since shaving cream is contraindicated in the hospital the last time shaving was performed because clients can only shave twice weekly in the hospital medications listed on the client's medication administration record (MAR) cultural views and attitudes toward facial hair and grooming (Correct - medications listed on the client's medication administration record (MAR) The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition." "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces." (Correct - "I will use conditioner so that the lice eggs will slide off my hair ." Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? "I know these spots are called senile lentigines and they are likely cancer." "All of these spots are called seborrheic keratosis and they should be taken off." "These brown spots are senile lentigines and are common when you get older." "Older people often have splotchy skin due to seborrheic keratoses." (Correct - "These brown spots are senile lentigines and are common when you get older." A febrile preschool -aged child presents to the after -hours clinic. Varicella (chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nu rse report? a. Vesicles b. Wheals c. Papules d. Pustules (Correct - a. Vesicles
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