Exam (elaborations)
(NURS 100) Assessment 2. WCU questions and answers graded A+ 2024/2025
- Course
- NURS 100
- Institution
- West Coast University
(NURS 100) Assessment 2. WCU questions and answers graded A+ 2024/2025
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(NURS 100) Assessment 2. WCU3.) Which nursing action is necessary for patient safety during a bed bath?
a. All four side rails are always kept in the raised position during the bath.
b. The bed is always in the low and locked position while bathing the patient.
c. The top side rail is raised opposite the side where the nurse is standing.
d. The bed is always kept in a flat position with a pillow under the patient's head. - ANS-c. The
top side rail is raised opposite the side where the nurse is standing.
The bed is raised to a comfortable working position and the side rail is lowered on the side
where the nurse is standing. It is important to leave the bed in the low and locked position with
the top side rails up when the bath is finished and the nurse is leaving the room. The position of
the bed and the patient during the bath is dependent on the patient's condition and comfort
level.
LO: 27.6
DIF: Applying
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Safety and Infection Control
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following
actions requires intervention? - ANS-Palpate the abdomen prior to performing auscultation
A home health nurse is conducting a home safety assessment for an older adult client. Which of
the following findings should the nurse identify as a safety risk for the client? - ANS-Water temp
(^120) Throw rugs
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the
following...? - ANS-Secure the restraints using a quick-release tie.
A nurse assesses a client who has a wrist restraint applied. For which of the following findings
should the nurse loosen the restraints? - ANS-The client's hand is cool and pale.
A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal
pain. the nurse asks the client whether he has nausea and has been vomiting. Which of the
following pain characteristics is the nurse attempting to determine?
A.Presence of associated manifestations
B.Location of the pain
C.Pain quality
D. aggravating and relieving factors - ANS-A
A. The nurse should attempt to identify manifestations that occur along with the clients pain,
such as nausea, fatigue or anxiety.
A nurse at an extended-care facility is instructing a class of AP about client use of assistive
devices during ambulation. Which of the following instructions... about the use of a cane? -
ANS-When the client moves, he should move the cane forward first
,A nurse if assessing a client's bowel sounds. At which of the following points in the assessment
should the nurse auscultate the client's abdomen? - ANS-Prior to percussing the abdomen
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify
as a risk factor for osteoporosis?
A. Drinks one alcoholic beverage per day
B. Smokes 1 pack of cigarettes per day
C. Large body stature
D. History of bone fracture during childhood - ANS-B. Smokes 1 pack of cigarettes per day
A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper
back/ which of the following is an intervention? - ANS-Pinch up a fold of skin to check for turgor
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse
should anticipate that the client will require teaching about which of the following medications?
A. Acetaminophen
B. Celecoxib
C. Cyclobenzaprine
D. Ibuprofen - ANS-A. Acetaminophen
A nurse in a family practice clinic is performing a physical examination of an adult client. Which
part of her hands should she use during palpation for optimal assessment of skin temperature?
A.Palmar surface
B.Fingertips
C.Dorsal surface
D.Base of the fingers - ANS-C
C. The dorsal surface of the hand is the most sensitive to temperature.
A nurse in a long term care facility enters the day room and finds the window curtains on fire.
Clients are panicking and the room is filling with smoke. Indicate the emergency actions the
nurse must take. - ANS-REMOVE
ACTIVE
CLOSE THE DOOR
EXTINGUISH THE FIRE
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis
that is affecting her knees. Which of the following client statements indicated an understanding
of the teaching?
A. "I can use either heat or ice to help relieve the discomfort."
B. "Ibuprofen is the first step in medication therapy for osteoarthritis."
C. "I should limit physical activity to prevent further injury."
D. "I will elevate my legs by placing two pillows under my knees when I go to bed. - ANS-A. "I
can use either heat or ice to help relieve the discomfort."
, A nurse in a provider's office is collecting a health history from a client who is at risk for primary
osteoporosis. Which of the following findings is a risk factor for the development of
osteoporosis?
A. Obesity
B. Sedentary lifestyle
C. Long-term use of diuretics
D. Prolonged stress - ANS-B. Sedentary lifestyle
A nurse in a provider's office is documenting his findings following an examination he performed
for a client new to the practice. Which of the following parameters should he include 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 general appearance portion of the general survey.
B. Skin lesions are part of the body structure or general appearance portion of the general
survey.
C. Speech is part of the behavior portion of the general survey
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal
system as part of a comprehensive physical examination. Which of the following findings should
the nurse expect? (select all that apply.)
A. concave thoracic spine posteriorly
B. exaggerated lumbar curvature
C. concave lumbar spine posteriorly
D. exaggerated thoracic curvature
E. Muscles slightly larger on his dominant side - ANS-C,E
C. The nurse should expect the client to have a concave lumbar spine posteriorly.
E. The nurse should expect the client to have muscle size equal on both sides or slightly larger
on the dominant side.
A nurse is assessing a client following the application of a leg cast for the treatment of a
fracture. If the cast is too tight, which of the following findings should the nurse expect to
observe first?
A. Change in temperature of the toes.
B. Pallor of the toes.
C. Edema of the toes.
D. Inability to move toes. - ANS-B. Pallor of the toes.
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