9/10/24, 3:45 AM
(NURS 100) Assessment 2. WCU
Jeremiah
Practice questions for this set
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d. Inspection, auscultation, percussion, palpation
Assessment of the abdominal cavity requires inspection then auscultation, percussion
then palpation to avoid stimulating the bowel and eliciting inaccurate assessment results.
Choose matching term
A nurse is providing teaching to a client who has osteoporosis and a new prescription for
alendronate. Which of the following adverse effects should the nurse instruct the client to report to
the provider?Tinnitus
1 Jaw pain
Blurred vision
Drowsiness
Dysphagia
A nurse is caring for a client who has an un-repaired femur fracture of the mid-shaft. Which of the
following techniques should the nurse use when performing an assessment of the client's
neurovascular status?
2 A. Measure the circumference of the thigh.
B. Palpate the femoral pulse.
C. Monitor the client's calf for edema.
D. Instruct the client to wiggle his toes.
(NURS 100) Assessment 2. WCU
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,9/10/24, 3:45 AM
Which sequence best identifies the order in which the nurse should complete an abdominal
assessment?
3 a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, percussion, palpation
Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed
assistive personnel (UAP)?
a. Assessing the patient for fall risk and complications of restraint use
4
b. Evaluating the patient's ability to perform activities of daily living (ADLs)
c. Assisting with or performing the patient's ADLs
d. Teaching the patient use of assistive devices
Don't know?
Terms in this set (116)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
Objective data can be gathered from the
e. Laboratory testing
patient during which aspects of the physical
assessment process? (Select all that apply.)
Objective data consist of observed information or signs that can be collected during all
stages of the physical assessment process. Even while the patient is answering
questions, providing subjective or symptom information, the nurse observes for
physical signs of abnormalities or impairment.
Which sequence best identifies the order in d. Inspection, auscultation, percussion, palpation
which the nurse should complete an
abdominal assessment? Assessment of the abdominal cavity requires inspection then auscultation, percussion
then palpation to avoid stimulating the bowel and eliciting inaccurate assessment
a. Inspection, palpation, percussion, results.
auscultation
b. Auscultation, inspection, palpation,
percussion
c. Auscultation, palpation, percussion,
inspection
d. Inspection, auscultation, percussion,
palpation
A nurse is preparing to auscultate a patient's a. Second right intercostal space
chest. In which area should the nurse listen
to evaluate the patient's aortic valve? The second intercostal space on the right is the auscultation point for the aortic valve.
The ventricles and pulmonic valve are located on the left. The point of maximal impulse
a. Second right intercostal space (PMI) over the mitral valve is located between the left fourth and fifth intercostal
b. Third left intercostal space spaces.
c. Fifth right intercostal space
d. Fifth left intercostal space along the
midclavicular line
(NURS 100) Assessment 2. WCU
2/20
, 9/10/24, 3:45 AM
The nurse notes the presence of ptosis when d. Oculomotor cranial nerve III paralysis
assessing an adult patient's eyes. Which
potential cause would be considered of Oculomotor paralysis may indicate the presence of a larger neurologic problem that
most concern, requiring further evaluation as requires further investigation as soon as possible. Loss of skin elasticity and muscle
soon as possible? weakness may be due to aging, and congenital ptosis does not require immediate
attention in an adult.
a. Loss of skin elasticity
b. Levator muscle weakness
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis
Which type of lung sounds does the nurse a. Vesicular
expect to auscultate over most of the lung
fields? Vesicular breathe sound are heard over most of the lung fields. Resonance is heard
with percussion, not auscultation. Dullness is heard over the solid organs (liver, heart).
a. Vesicular Flat sounds are heard over the stomach and intestines.
b. Resonant
c. Dull
d. Flat
When teaching a patient about fire safety, a. Cooking
which activity does the nurse know is the
leading cause of fire-related death? Cooking I the leading cause of residential fires for the last decade, followed by heating,
electrical malfunction. And other unintentional causes or carelessness.
a. Cooking
b. Playing with matches
c. Smoking
d. Heating with kerosene heaters
Which measures can the nurse teach to a. Install safety latches on reachable cabinets.
prevent poisoning of children? (Select all c. Use childproof caps on medications.
that apply.) d. Use a plunger rather than a chemical drain cleaner.
a. Install safety latches on reachable Child locks for cabinet and childproof caps for medication bottles are recommended
cabinets. to prevent poisoning. The use of alternatives (e.g. plungers) rather than toxic chemicals.
b. Keep syrup of ipecac on hand. (e.g. Drano) is recommended to prevent ingestion of deadly substances. Syrup of
c. Use childproof caps on medications. ipecac has been used in the past to treat poisoning after it occurred and is not
d. Use a plunger rather than a chemical drain considered a preventive measure. Keeping cleaning supplies under the kitchen sink is
cleaner. dangerous because the area is within reach o children.
e. Keep cleaning supplies under the kitchen
sink.
Which restraint-free alternative is best for the b. A pressure sensor alarm and a room near the nurses' station
nurse to use for an 84-year-old patient after
hip replacement who has confusion and Patients with confusion may not remember to call for assistance before getting up,
incontinence? especially if they have had an episode of incontinence. A pressure sensor alarm that
can be used in a bed or chair should be implemented as a priority intervention along
a. A room near the nurses' station and with moving the patient to a room near the nurses station, where the patient be more
decreased sensory stimuli closely monitored. Although decreasing sensory stimuli may help patient with
b. A pressure sensor alarm and a room near confusion, it is not a priority intervention. A 24-hour sitter is costly and used only after
the nurses' station all other restraint-free alternative are exhausted.
c. Side rails up and decreased sensory
stimuli
d. A 24-hour sitter and the patient's favorite
TV program
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