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Skills Question (Health Assessment) Questions and Answers
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Skills Question (Health Assessment)
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Skills Question (Health Assessment)The nurse is preparing to conduct a 10-minute head-to-toe assessment on a client
admitted with pneumonia. What should the nurse do first? - answer Complete a general
inspection.
An emergency room nurse is conducting a quick head-to-toe assessment of a client
reporting flu-like symptoms. What pulse grade would the nurse document if the client's
radial pulses were "full, easy to palpate, and cannot be obliterated"? - answer+2 pulse
The nurse is performing a quick head-to-toe assessment on a client admitted with an
infected left heel wound. When auscultating the lower lobes of the client's lungs, what
might the nurse expect to find? - answerSoft, low pitched sounds bilaterally
The nurse is planning to assess an older adult client admitted with abdominal pain.
Which special considerations are important to contemplate when assessing the older
adult client? Select all that apply. - answerShort term memory may diminish with age.,
Older adults take longer to perform certain actions., Presence of heart sound S4 is
considered normal.
The nurse is completing a quick head-to-toe assessment on a client admitted with right-
sided heart failure. Which body parts should be examined for peripheral edema? Select
all that apply. - answerSacrum, Feet, Hands
A nurse is preparing to perform a general survey of a client. What equipment would the
nurse require to perform this assessment? Select all that apply. - answerStanding scale,
Tape measure, Sphygmomanometer, Stethoscope
Which senses are used when the nurse performs the inspection phase of assessment?
Select all that apply. - answerSmell, Hearing, Sight
When performing a general survey assessment, how would the nurse assess the
client's orientation? Select all that apply. - answerQuestion where the client is now.,
Query about today's date and season., Request the client states his or her name.
The nurse is preparing to obtain biographical data from a client before initiating a health
assessment. Which biographical data should the nurse plan to collect? Select all that
apply. - answerGender, Occupation, Date of birth, Name
The nurse is about to conduct a general survey on a client being admitted to the
medical-surgical unit. What should the nurse do first? - answerIdentify the client by two
methods.
, The nurse is asking admission interview questions, and the client has explained the
reason for seeking care. Which is the most appropriate way to document the response?
- answerClient states, "I feel winded all of the time, and yesterday I started spitting up a
lot of phlegm."
The nurse is performing a general survey on a client who is being admitted to the
medical unit with abdominal pain. Which components would the nurse assess during the
general survey? Select all that apply. - answerAssess the client's vital signs
The nurse is beginning a general survey on a client who is being admitted to the
hospital for abdominal pain. After identifying the client, which components would the
nurse include in the general survey? Select all that apply. - answerDoes the person's
body structure match the stated age?, Is the client's color appropriate for ethnicity?, Are
there any tubes, lines, or drains?, Does the client appear to be alert?
The nurse must weigh a client using a bed scale. Place the following steps in the correct
order. Use all options. - answer1)Place a cover over the sling of the bed scale.
2)Attach the sling to the bed scale.
3)Balance the scale so that weight reads 0.0.
4)Roll client back over the sling and onto other side.
5)Gradually elevate the sling so that the client is lifted up off of the bed.
6)Note weight reading on the scale.
The surgical nurse is caring for four clients. Which tasks can the nurse delegate to the
unlicensed assistive personnel (UAP)? Select all that apply. - answerAttaining an
admission weight for a client using a portable bed scale., Documenting the urinary
output of the client with a Foley catheter., Ambulating the client who is third day
postoperative from right knee surgery.
A nurse is caring for a client requiring daily weights. What nursing actions are indicated
when obtaining a weight using a portable bed scale? Select all that apply. -
answerAttach the sling to the bed scale and cover with a bath blanket., Perform hand
hygiene and put on personal protective equipment, if indicated., Close the curtains
around the bed and close the door.
The nurse needs to obtain an admission weight for a client diagnosed with end-stage
lung cancer. To obtain the client's weight, what should the nurse do first? -
answerAssess the client's ability to stand or sit.
The nurse weighs the client using a portable bed scale. The obtained weight is 10 lb
(4.5 kg) more than the nurse expected. What action does the nurse take next? -
answerEnsure equipment is not hanging into the sling.
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