A nurse is beginning a head to toe assessment for a client. In general, what order should the tasks be performed for each body system?

A nurse is precepting a nursing student. Which action by the nursing student requires intervention by the nurse?

A nurse is caring for a client who is visually impaired. What action by the nurse will decrease anxiety in this client?

A client has been brought to the pre-op area to have his IV started before undergoing hernia surgery. The client is extremely anxious and starts crying when the nurse walks into the room. Which intervention would be most appropriate in this situation to help with the client’s anxiety?

When caring for a client who is hearing-impaired, the priority nursing action is which of the following?

After receiving a terminal diagnosis of congestive heart failure, a client is hostile to family members and hospital staff. The family is upset by this and asks why the client is so hostile. Which of the following responses by the nurse is most appropriate?

A client in the hospital has a Hispanic background and does not speak English. The nurse tries to call an interpreter but no one is available, so the nurse opts to use the client’s adolescent son as an interpreter. Which of the following must the nurse consider when using a family member as a language interpreter? Select all that apply.

A nurse is caring for an Asian client who is being seen for a bleeding disorder. Whenever the nurse enters the room, the client averts her eyes and avoids eye contact. She answers the nurse’s questions but refuses to look at the nurse. Which of the following is the client most likely demonstrating?

A nurse is caring for a client who needs an MRI for a back injury. The client is deaf. The nurse has provided written information for the client but needs to find out if there are any questions. In which way would the nurse most likely act as the client’s advocate?

A client has been diagnosed with antisocial personality disorder and becomes very angry with the nurse and is starting to become aggressive. Which principle of management would most likely be implemented in this situation?

In helping a blind client have a sense of safety and security, the nurse should do which of the following? Select all that apply.

The nurse is admitting a client to the unit with a history of mechanical heart valve, hemodialysis with a left arm fistula, benign prostatic hypertrophy, diabetic neuropathy in bilateral lower extremities, diabetes mellitus, and hypertension. A nursing assistant is available to obtain the client’s vital signs. What is the most important item to pass on to the nursing assistant regarding this task?

A nurse is performing an abdominal assessment on a client who complains of abdominal pain. Which of the following would be subjective information about the client? Select all that apply.

A nurse is preparing for a focused assessment of the chest and lungs of a client. Which position is best for the nurse to place this client?

A 66-year-old client is being seen for a skin assessment. The nurse notes several brown spots on the client’s face that the client refers to as liver spots. What is the technical term for this condition?

A client is brought to the emergency room with complaints of abdominal pain. The nurse performs a focused abdominal assessment. Which of the following is an element of the inspection portion of the exam? Select all that apply.

A client is brought to the recovery room after hip surgery. The nurse performs an initial assessment of the client’s respiratory and hemodynamic status. Which of the following signs or symptoms would most likely indicate a complication during this period?

Which of the following questions help the nurse determine the quality of pain a patient is experiencing? Select all that apply.

A client is recovering from knee surgery in the orthopedic unit. The client winces with movement and doesn’t want to get up, but denies being in pain during the nurse’s pain assessment. Which of the following is an appropriate response from the nurse? Select all that apply.

Which best describes the order in which the nurse should assess a client’s abdomen?

Twelve hours after abdominal surgery, the nurse assesses the client and notes restlessness and complaints of thirst. The nurse notes that the client has cool, pale extremities, tachycardia and has become diaphoretic. The nurse notes that the dressing to the surgical site is soaked with blood. Which of the following is the next action the nurse should take?

A nurse is assessing an adult client in the emergency department who has a respiratory rate of 32/minute. Which of the following are potential causes of tachypnea? Select all that apply.

At 10am, a client’s vital signs are as follows: HR 92, BP 128/84, RR 20, Temp 99.0. At 10:30, the nurse notes the client’s rhythm strip above on the monitor at the nurse’s station. Which of the following should the nurse’s first action be?

After having surgery for a shoulder replacement under general anesthesia, the client became excessively hot with a temperature of 104.5F. The nurse would be concerned about which of the following?

A client has been brought into the emergency department after being involved in a car accident. The nurse applies a probe to the client’s finger to measure the oxygen saturation levels. Which factors would affect the ability to obtain a normal oxygen saturation reading? Select all that apply.

The nurse obtains vital signs on a febrile client. Which vital sign is not expected and needs to be addressed first?

A nurse is utilizing the PQRST pain assessment method to determine if a client is experiencing pain. Which questions would the nurse ask according to the P portion of the assessment? Select all that apply.

A nurse enters the room and notices her client has a heart rate of 132 on the monitor. The nurse knows that which of the following is the priority nursing intervention?

A nurse is working with a client who has been infected with methicillin-resistant staphylococcus aureus (MRSA). The nurse needs to check the client’s vital signs using a blood pressure cuff that is normally kept in the central supply area of the unit. Which action should the nurse perform that is most appropriate to prevent spread of this infection?

The nurse just received reports on the following four clients Which client should the nurse see first? 1) A 54-year-old with a blood pressure of 140/90 mmHg 2) An 89-year-old with a heart rate of 110 3) A 40-year-old with a respiration rate of 30 breaths per minute 4) A 91-year-old who needs to use the bathroom.

The nurse receives report on a client with active chest pain and a type B aortic dissection noted on CT. The client has an arterial line placed. Which is the most important vital sign to monitor?

The nurse is attempting to count the heart rate on an EKG graph and notices the client has an irregular rhythm. The nurse knows that which of the following is the best method to obtain an accurate heart rate?

A nurse is providing newborn care education to first time parents. The parents ask how to take the baby’s temperature. Which is the most recommended and most accurate route for taking an infant’s temperature that can be suggested to the parents?

In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. During the client interview, the nurse wants to assess the client’s background and health history. Which of the following are examples of leading questions that the nurse should avoid? Select all that apply.

During an initial assessment of a client with coronary artery disease, the nurse wants to assess the client’s dietary intake to determine if diet is contributing to his health condition. Which question would most likely give the nurse an idea of the client’s everyday diet?

The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? Select all that apply.

A nurse is counseling a client who has hypertension and type 2 diabetes. During the initial assessment, the nurse notes that the client has a blood pressure of 148/92 mmHg, a BMI of 28, and a blood glucose level of 161 mg/dL. Which of the following information about health and wellness would be most beneficial for the nurse to teach this client?

The nurse is charting a skin assessment on the newly admitted client. The client has a flat and non-palpable discoloration on their leg that is less than one cm in size. The nurse should chart this using what terminology?

An older adult client is often incontinent of stool in his bed. He has started to develop an area of skin breakdown on his sacrum. In which ways does stool incontinence contribute to skin breakdown? Select all that apply.

There are 4 clients in the emergency room that have some sort of laceration or cut. Which laceration should the nurse see first?

A client just found out they have seborrheic keratosis. The client asks, “How much longer do I have to live?” Which of the following is the best response by the nurse?

Which of the following findings would the nurse expect to find during a skin assessment for a client with vasculitis?

A nurse is providing skin care to a client who has been incontinent in the bed. The nurse knows that incontinence causes skin breakdown through maceration of the skin. Which describes how maceration occurs through incontinence? Select all that apply.

A 79-year-old client has an appointment at a dermatology office for a skin assessment and removal of a suspicious mole. The nurse assesses the client’s skin texture and turgor. Which types of skin issues would the nurse most likely see in an older adult? Select all that apply.

A nurse is caring for a client with morbid obesity. Which best describes this client’s risk of skin breakdown related to their weight?

The nurse is charting a skin assessment on the newly admitted client. The client has cuts on the wrists from attempted suicide. The nurse should chart this using what terminology?

A nurse who works in a long-term care facility has noted that one of her clients is frequently incontinent of urine and stool. The client also has mobility issues and the nurse is concerned about skin breakdown in this client. Which actions should the nurse perform to prevent skin breakdown? Select all that apply.

The nurse has just received a trauma client in the emergency department. The trauma assessment reveals a patent airway, breathing within normal limits, and appropriate circulation. Which of the following should be done next?

A nurse is eating dinner in a restaurant when a person at the next table stands up and clutches her hands to her throat, making the universal sign for choking. The nurse asks the person if she is choking and she nods her head yes. She makes squeaking sounds while trying to talk and can cough. How should the nurse respond to this situation?

A nurse is caring for a client in the hospital who has been admitted with an infection. During the first assessment, the client tells the nurse that he has a severe headache and cannot turn his head. He complains of the light hurting his eyes. Which response of the nurse is most appropriate?

Which of the following is the most important thing to ask an oriented client who hit their head during a fall?

The nurse is charting a skin assessment on the newly admitted client. The client has a palpable blood filled bump on the forehead from a fall. The nurse should chart this using what terminology?

A nurse is caring for an unconscious client who is recovering from a head injury. The client is sedated with an intracranial monitor in place, and the nurse is charting the client’s pain level. Which of the following pain assessment methods are appropriate in this situation? Select all that apply.

The nurse is caring for a client who is suffering from a migraine headache. Which of the following is an appropriate nursing intervention?

A school nurse is notified of a student who appears to be having an allergic reaction. The student has red blotches all over her face and neck, her face and tongue are swollen, and she is wheezing while trying to breathe. Which is the most appropriate actions the nurse should take in response? Select all that apply.

A client with significant stress is experiencing muscle tension and pain in the neck and shoulders. Which of the following non-pharmacological methods has been shown to relieve muscle spasms?

A client presents to the ER after a motor vehicle crash that happened yesterday. The clients states that today they woke up with neck pain and it now hurts to look to the left. What is the priority nursing intervention for this client?

The nurse is caring for a client with a fever, headache, and stiff neck. Which intervention is the priority for this client?

A client presents to the emergency department with a foreign object sticking out of the left eye. Which of the following is a priority intervention? Select all that apply.

A client has strabismus. Which of the following would the nurse expect to see during assessment?

A nurse is caring for a client who is experiencing farsightedness. The nurse knows another name for this is which of the following?

A nurse is caring for a 71-year-old client who has demonstrated some hearing loss and started to use a hearing aid. Which findings would the nurse expect if the client is using the hearing aid correctly? Select all that apply.

The nurse notes that the client has conductive hearing loss. Which of the following contribute to this type of hearing loss? Select all that apply.

The nurse is caring for a client with otitis media. Nursing interventions to treat this condition include which of the following? Select all that apply.

A nurse is caring for a client who is experiencing eye movements that are out of sync with each other. Which of the following terms is appropriate for this finding?

The nurse is caring for a child with acute otitis media. Which of the following are appropriate nursing interventions for this child? Select all that apply.

A nurse is helping a client to remove dentures from the top of the mouth. Which best describes how the nurse should assist?

A mother brings her 2-month old child in for a well baby visit and reports concern that the child has its eyes crossed most of the time. What is the most appropriate response by the nurse? Select all that apply

During a cardiac assessment, the nurse notes that upon auscultation of the client’s heart, the pulse is regular but the volume of the pulse diminishes every other beat. This condition is best described as which of the following?

A client who is recovering from cardiac catheterization has developed low blood pressure and jugular venous distention. The nurse auscultates the client’s chest and notes clear lung sounds, but muffled heart sounds. Which action would the nurse perform first?

The nurse is caring for a client after surgery. The client’s lung sounds are clear on the left and soft, distant crackles on the right side. The nurse reviews the image above on the morning chest x-ray. Which intervention would be most appropriate for this client?

A client is being seen in the emergency department for abdominal pain. Based on the client’s history, the nurse believes the client may have an abdominal aortic aneurysm. Which method of physical assessment should the nurse employ in this situation?

The nurse is caring for a client who is recovering from an inguinal hernia repair. Which of the following nursing interventions are appropriate? Select all that apply.

The nurse in the trauma bay is caring for a client brought in after falling off of a roof onto a car. During the initial assessment, the resident states the client has a positive FAST exam. The nurse knows this indicates which of the following?

The nurse is talking with a client who has just been diagnosed with Paget’s disease. The nurse knows that this is a disorder that affects which organ?

A home care nurse is working with a client who has a self-care deficit related to a musculoskeletal disorder. The nurse notes that the home health aide who works with this client asks the client to try to eat independently as much as possible. Which of the following best describes the most likely rationale for this?

A nurse who is working on the rehabilitation unit of the hospital has been assigned the following clients: Client A is a 39-year-old who has a musculoskeletal condition that requires chiropractic alignment once a week. Client B is a 50-year-old who has vision loss and needs 1-person assist with movement. Client C is a 68-year-old who suffers from tinnitus due to an inner ear disorder. In which order should the nurse see these clients to support their needs for movement and rehabilitation?

A nurse who works in a rehabilitation unit is at the healthcare clinic for back pain. The nurse receives a diagnosis of an advanced-stage musculoskeletal injury in the lower back and has orders to remain on bed rest for the next week. Which best describes symptoms associated with an advanced stage musculoskeletal injury in this situation? Select all that apply.

The nurse is setting up for an examination of a client in the clinic. The nurse obtains items for the provider to conduct a papanicolaou test. What is the age range for a client receiving this test?

The nurse is performing an admission assessment on a client who claims to have multiple sexual partners. The client denies any signs or symptoms of a sexually transmitted infection. Which of the following teaching points is true for this client?

The nurse is assessing a client who reports new onset dysuria, and vaginal discharge that is green in color. The nurse suspects which of the following sexually transmitted infections?

The nurse is caring for a 35-year-old client who reports a history of syphilis infection discovered at age 25. The nurse knows that which of the following is true regarding syphilis at this stage?

The nurse is interviewing a client who reports they have a new sexual partner. The client states they have burning with urination and new-onset penile discharge that has an odor. The nurse suspects which of the following conditions?