Exam 2 Flashcards
- A nurse in a provider’s office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.)
A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion
A. Smaller Nipples
D. More pendulous
E. Nipple inversion
- A nurse in a provider’s office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)
A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds
C. Resonance
D. Tactile fremitus
E. Bronchovesicular sounds
- During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
A. Fat
B. Fluid
C. Flatus
D. Hernia
C. Flatus
- During a cardiovascular examination, a nurse in a provider’s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.)
A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur
B. Closure of the mitral valve
D. Closure of the tricuspid valve
- When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse
A. keep the sterile field at least 6 ft away from the client’s bedside.
B. instruct the client to refrain from coughing and sneezing during the dressing change.
C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.
D. keep a box of facial tissues nearby for the client to use during the dressing change.
C. place a mask on the client to limit the spread of micro-organisms into the surgical wound.
- A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)
A. A bottle containing a sterile solution
B. The edge of the sterile drape at the base of the field
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand
- A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
A. The flap closest to the body
B. The right side flap
C. The left side flap
D. The flap farthest from the body
D. The flap farthest from the body
- A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.)
A. Apply 3 to 5 mL of liquid soap to dry hands.
B. Wash the hands with soap and water for at least 15 seconds.
C. Rinse the hands with hot water.
D. Use a clean paper towel to turn off hand faucets.
E. Allow the hands to air dry after washing
B. Wash the hands with soap and water for at least 15 seconds.
D. Use a clean paper towel to turn off hand faucets.
- A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.)
A. The provider drops a sterile instrument onto the near side of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field.
C. The procedure is delayed 1 hr because the provider receives an emergency call.
D. The nurse turns to speak to someone who enters through the door behind the nurse.
E. The client’s hand brushes against the outer edge of the sterile field.
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field
- A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.)
A. Planning and evaluating control and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks
A. Planning and evaluating control and prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
E. Monitoring for common-source outbreaks
- A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply.)
A. Place the client in a room that has negative air pressure of at least six exchanges per hour.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
D. Use sterile gloves when handling soiled linens.
E. Wear a gown when performing care that may result in contamination from secretions.
B. Wear a mask when providing care within 3 ft of the client.
C. Place a surgical mask on the client if transportation to another department is unavoidable.
E. Wear a gown when performing care that may result in contamination from secretions.
- A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?
A. Allergic reaction
B. Ringworm
C. Systemic lupus erythematosus
D. Herpes zoster
D. Herpes zoster
- A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymphnodes. The client is experiencing which of the following stages of infection?
A. Prodromal
B. Incubation
C. Convalescence
D. Illness
D. Illness
- A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply.)
A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate
A. Fever
B. Malaise
E. Increase in pulse and respiratory rate
- 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. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
A. A concave thoracic spine posteriorly
C. A concave lumbar spine posteriorly
E. Muscles slightly larger on his dominant side
- A nurse is evaluating a client’s neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items?
A. A word she whispers 30 cm from his ear
B. A number she traces on the palm of his hand
C. The vibration of a tuning fork she places on his foot
D. A familiar object she places in his hand
D. A familiar object she places in his hand
- A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
A. Mopping her floors
B. Brushing the back of her hair
C. Fastening her bra behind her back
D. Reaching into a cabinet above her sink
C. Fastening her bra behind her back
- A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client’s balance? (Select all that apply.)
A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A. Romberg test
B. Heel-to-toe walk
- A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.)
A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation
B. Some vision and hearing decline
C. Slower fine finger movement
D. Some short-term memory decline
- A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, “How could you possibly understand what I am going through?” Which of the following is an appropriate response by the nurse?
A. “It takes time to get over the loss of a loved one.”
B. “You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling.”
C. “Why don’t you try something to take your mind off your troubles, like watching a funny movie.”
D. “I might not share your exact situation, but I do know what people go through when they deal with a loss.”
B. “You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling.”
- A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?
A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction
C. Alarm reaction
- A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at thistime? (Select all that apply.)
A. Suggest coping skills for the client to utilize in this situation.
B. Allow the client to provide input in the treatment plan.
C. Assist the client with time management, and address the client’s priorities.
D. Provide extensive instructions on the client’s treatment regimen.
E. Encourage the client in the expression of feelings and concerns.
B. Allow the client to provide input in the treatment plan.
C. Assist the client with time management, and address the client’s priorities.
E. Encourage the client in the expression of feelings and concerns.
- A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client’s role problem?
A. Role conflict
B. Role overload
C. Role ambiguity
D. Role strain
A. Role conflict
- Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis?
A. Prescribing tasks unilaterally
B. Delegating care to one member
C. Speaking to the primary client privately
D. Convening a family meeting
D. Convening a family meeting
- A nurse in a provider’s office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the client’s difficulty sleeping? (Select all that apply.)
A. Does your lack of sleep interfere with your ability to function during the day?
B. Do you feel confused in the late afternoon?
C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?
D. Has anyone ever told you that you seem to stop breathing for a few seconds while you
are asleep?
E. Tell me about any personal stress you are experiencing.
A. Does your lack of sleep interfere with your ability to function during the day?
C. Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?
D. Has anyone ever told you that you seem to stop breathing for a few seconds while you
are asleep?
E. Tell me about any personal stress you are experiencing.
