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

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

A diabetic client in the care clinic is complaining of feeling anxious. The nurse notes that the client is sweaty, has tremors, and is tachycardic. Which intervention would the nurse most likely perform in response?

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?

The nurse is caring for a client who is blind. The nurse should perform which of the following actions to best communicate with this client? Select all that apply.

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?

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

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 on the medical-surgical unit has been assigned to a client who is legally blind and recovering from abdominal surgery. Which interventions would the nurse implement when caring for this client in order to best uphold the client’s safety while in the hospital? Select all that apply.

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 nurse is caring for a postpartum client who is Vietnamese and speaks little English. Because of complications with delivery, the mother experienced a larger amount of blood loss, and the provider has ordered an increase in IV fluids as well as encouraging oral intake of fluids. The nurse brings the mother a pitcher of ice water and the client becomes visibly upset. Which response from the nurse is most appropriate?

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 nurse is assessing a client’s nutritional status. In addition to checking the client’s weight, which of the following assessments would the nurse include to check for malnutrition?

A nurse is palpating a client’s abdomen to check for an abdominal aortic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding?

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.

A nurse is assessing a 4-year-old child who is being seen for fever and vomiting for the last 24 hours. The nurse checks the child’s vital signs and notes that the respiratory rate is 28/minute. Which actions should the nurse take in response? Select all that apply.

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.

A nurse is working with a 70-year-old client with hypovolemia. The nurse assesses the client and finds she has cool extremities and a weak pulse. Additionally, no urine output has been charted on the client for seven hours. Which of the following outcomes is an appropriate treatment goal for this client?

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?

A postpartum client complains that she gained a lot of weight during her pregnancy and that her ankles are swollen. The nurse assesses her feet and lower legs for edema. Which actions would be part of assessing peripheral edema? Select all that apply.

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.

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.

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 client was found lying outside in the snow unconscious and brought to the emergency room. Upon assessment, the nurse finds that the client has a temperature of 92.1 F and the nurse is unable to palpate the left radial pulse. The nurse should do which of the following 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.

The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?

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?

The nurse is caring for a client with a heart rate of 150 bpm, a blood pressure of 70/44, respirations at 28 per minute, and an O2 saturation of 91%. Which of the following interventions should the nurse anticipate doing next??

The nurse is caring for a client with the following vital signs: temp 101.4F, pulse 105, pulse ox 99%, respiration rate 20, blood pressure 125/71. The nurse would suspect which of the following labs to be elevated?

A client came in with a temperature of 105F. On assessment the nurse notes the client to be confused. The client is hot to the touch but not sweaty and has a weak pulse. The nurse should implement which of the following precaution types for this client?

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 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?

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?

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

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?

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.

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

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.

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 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 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?

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?

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.

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.

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.

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 client who is receiving radiation treatments in the head and neck complains of a dry mouth after treatment. Which of the following pieces of advice would be best for the nurse to give to this client?

A nurse is performing a focused assessment on the head and neck of a 3-year-old child with an upper respiratory infection. Several of the child’s lymph nodes are enlarged, indicating an infectious process, and the nurse is able to palpate many of the lymph nodes. Which of the following nodes would most likely not show up as enlarged on a head and neck exam?

The nurse is caring for a client with a head injury. The client is experiencing increasing intracranial pressure (ICP). Which of the following findings is most consistent with this condition?

A 90-year-old client was brought in for care of a subdural hematoma after falling and hitting her head at home. Based on the nurse’s knowledge of this type of head injury, the nurse knows to look for which of the following signs or symptoms? Select all that apply.

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 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 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?

The emergency department nurse is evaluating a head injury client by assessing the six cardinal positions of gaze. Which of the following cranial nerves are being assessed? Select all that apply.

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?

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.

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

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

A client complains that he has developed a chronically dry mouth after taking his daily medication. What information can the nurse provide that would most likely help him to manage this condition?

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

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

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.

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.

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 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.

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?

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?

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 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 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?

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?