NURS 210 Final Exam Study Guide
when documenting subjective data for the cardiovascular system the nurse would include which of the following?
a vital signs b peripheral pulses c chest pain d heart sounds (Ans- chest pain
when responding to questions asked during a review of systems, the client reports having a sore throat which "happens all the time." The nurse should ask which question next?
a when did this sore throat begin?b what do you mean you have sore throats all the time?c did you also have sore throats as a child?d did you ever take antibiotics?(Ans- when did this sore throat begin?
the nurse is gathering present health data during the health history assessment. The nurse asks the client about alcohol use. The client angrily asks, "why do you need to know?" what is the nurse's best response?
a if you consume alcohol then I will need to provide alcohol counseling b I need to know because alcohol can interact with many medications c you are very defensive. this suggests you probably have an alcohol problem d I can make a referral to alcohol self-help groups for you (Ans- b I need to know because alcohol can interact with many medications
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Prior to obtaining data for a health history, the nurse should take which action?a introduce self to client and position client comfortably in a chair b bring in a family member to verify all data c review medical record to validate client information d tape record client information to avoid omissions (Ans- a introduce self to client and position client comfortably in a chair
Which question would the nurse ask to gather information about the client's health beliefs?a what is the name of the clinic you usually attend?b can you tell me about your current abdominal pain?c what do you think it means to be healthy?d what type of health insurance do you have?(Ans- c what do you think it means to be healthy?
The nurse is performing a physical assessment and is unable to palpate a pulse. What is the best action to take next?
a ask another nurse to check for a pulse b notify the healthcare provider about the finding c page the nursing supervisor to palpate the pulse d verify the finding with a doppler ultrasound (Ans- ask another nurse to check for a pulse
To assess vibration during a physical assessment, the nurse would use which part of the hand?(Ans- ulnar aspect
Upon completion of the physical examination of a client, the nurse should take which action?
a have another nurse confirm all findings b notify the healthcare provider of all findings c inform the client of the findings 2 / 4
d verify all findings with client (Ans- d verify all findings with client
a client who is mildly anxious is to undergo a physical assessment. Which of the following is the most appropriate action for the nurse to take?
a stay with the client at all times to provide assistance b use an unhurried manner and reassure client as necessary c proceed with the exam by completing the most invasive aspects first d ask for a consult to assess the extend of the anxiety (Ans- b use an unhurried manner and reassure client as necessary
during a cardiovascular assessment the nurse finds a bluish tinge on the client's lips, fingers, and toes. What is the appropriate documentation for this?
a central cyanosis b peripheral cyanosis c cyanosis d central and peripheral cyanosis (Ans- central and peripheral cyanosis
when preparing to perform a cardiovascular assessment, the nurse should initially place the client in which position?
a prone b supine c sitting upright d lithotomy (Ans- b supine
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In the client with mitral regurgitation the nurse would confirm the presence of a murmur at which location?
a apex b aortic area c pulmonic area d second intercostal space (Ans- apex
during a respiratory assessment, the nurse would elicit fremitus by doing which of the following?
a placing the hands over anterior and posterior lung fields, asking the client to say "ninety-nine" b asking the client to say "ninety-nine" while listening to the lung fields with a stethoscope c palpating the anterior, posterior and costal margins d percussing over the anterior and posterior chest (Ans- a placing the hands over anterior and posterior lung fields, asking the client to say "ninety-nine"
the nurse has auscultated the client's lungs and hears a bubbling sound bilaterally in the lower lung fields. The nurse would document which finding?a bilateral rhonchi at the bases b expiratory wheezing c bilateral crackles in the bronchi d bilateral crackles at the bases (Ans- d bilateral crackles at the bases
where are the bases at on the lungs?(Ans- the bottom
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