Hesi Questions practice quiz - exam 3 Flashcards
When obtaining a health history from the newly admitted clinet who has chronic pain in the right knee, which pain assessment data would the nurse include?
Pain history : including location, intestity, and quality of pain
Pain pattern: including percipiating and alleviating factors
Which action would the nurse take for a patient whose right radial pulse is weak and thready?
- Assessing all peripheral pulses
- assessing and comparing both radial pulses
- asking a second nurse to assess
- assessing for edema or other issues that may restrict peripheral blood flow
- observing for pallor/skin temp differences. Distal to the weak pulse
Which question would the nurse ask the pt when obtaining their health history?
- tell me about your food habits?
- do you use alcohol or tabacco?
- have you ever experience any allergic reactions?
Testing pulse assessment- Dorsalis pedis
located on the top of foot, this site is used to assess the status of circulation in the foot
Testing pulse assessment- ulnar site
located on the ulnar side of the forearm at the wrist- this site is used to assess the status of circulation to the hand
Testing pulse assessment-Carotid
found along the medial edge of the sternocleidomastoid muscle of the neck- mainly used in time of physiological shock
Testing pulse assessment- Posterior tibial
below the medial malleolus it is used to assess the status of circulation in the foot
which action would the nurse take first when caring for a postop client who reports pain?
perform a focused assessement of the patient
to assess the status of circulation to to the foor which sitw ould the nurse monitor for a pulse?
- dorsalis pedis artery
- posterior tibial artety
what artery is good in assessing the circulation to the lower leg?
femoral artery
The nursing student, under the supervison of the RN plans to perform a pulse assessment. While preparing the assess the pt, the RN asks the student to check the apical pulse after assessing the radial pulse. Which rational supports the RN request ?
the client may have a dysrhythmia
When assessing a client reporting SOB, which activity best ensures the nurse obtains accurate and complete data to prevent a nursing diagnostic error?
assess the clinets lungs
when preparing to assess the four abdominal quadrants of a pt who reports stomach pain, when would the nurse assess the sympotomatic quadrant?
Last
the nurse would systematically assess the abdomen concluding with the symptomatic area which is the area the pt reports pain
Upon noticing a pt with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis?
the lips
A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is MOST important and would be perfromed first?
assess the patency of airway
the nurse would assess the airway first because surgery and anesthesia may impair the patency of airway
which step of the nursing process invloves the nurse interviewing a client about a current health problem and obtaining the clients VS?
Assessement
Which documentaion is MOST informative for an assessment of drainage on a surgical dressing?
a 10mm- diameter area of drainage at 1900 is objective data and gives specific details
which information would the RN provide to a SN about the importance of nurisng documention for risk management?
- a nurse documentation is the evdence of care that a pt receives
- the nurse would note assessments and significant changes in the clients health
- nurse would always document the primary health care providers responses whenever they are contracted
a RN is teaching a NS about the proper techniques of an abdominal assessment. which order of assessment indiciates effective learing?
- inspects abdominal mobility
- note the position of the umbilicus
- auscultate
- palpate abdomen
In which situation would the nurse consider family members the primary source of information
- the pt is an infant or child
- the pt is brought in as an emergency
- the pt is critically ill and disoriented
The nurse performs a respiratory assessment and ascultates high-pitched, creaking, and accentuated breath. Sounds on expiration. Which term describes the findings?
Wheezes
While assessing a Pt ROM, the nurse explains adduction to the UAP. Which UAP statement indicated effective?
” I will ask the pt to move their arm toward their body”
Which physical assessment technique involves listening to the sounds of the body?
Auscultation
Which reliable site would the nurse utilize to assess a pt for Jaundice?
- Sclera
in which order to assess the abdomen?
inspection
auscultation
percussion
palpation
While assessing a pt with dehydration, the nurse notices disminished skin elasticity, which portion of the nurses hand would the nurse perform this assessment?
fingertips
the nurse assess a pt pulse and documents the strength of the pulse as 3+. what is the pulse strength?
Full
which pt assessment finding would the nurse document as subjective data?
pain rating of 5
while assessing a pts vascular system the nurse finds a disminished and barly palpable pulse strength. Which documentation would the nurse utilize?
1+
When assessing the carotid pulses, which term refers to a blowing sound created by blood turbulence when passing through narrowed arteries?
Bruit- an audible blowing sound associated with turbulent blood flow through a carotid artery
The nurse assess the lungs of a pt and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?
Crackles
Which cranial nerve does the nurse assess the function when asking the pt to shrug shoulders and turn head against passive resistance?
cranial nerve XI
When assessing a pt who experiences an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve?
Abducens nerve VI
