fundamentals week 3

The nurse suspects that a client has a distended bladder. Which method is correct to assess for this condition?

• Inspect and palpate in the epigastric region.

• Auscultate and percuss in the inguinal areas.

• Percuss and palpate in the hypogastric region.

• Percuss and palpate bilaterally in the lumbar areas.

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

• Presence of dry skin

• Loss of body weight

• Decrease in blood pressure

• Altered general appearance

The registered nurse notices that the student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. Which is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg?

• 130/80 mm Hg

• 150/100 mm Hg

• 140/100 mm Hg

• 130/100 mm Hg

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When would the nurse assess the symptomatic quadrant?

• first

• second

• third

• last

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as?

• vesicular

• bronchial

• crackles

• rhonchi

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. Which might the client’s body temperature be?

• 29 c

• 33 c

• 36 C

• 38 C

A registered nurse is teaching a nursing student about when a client with high blood pressure would follow up with the primary health care provider. Which statement made by the nursing student indicates effective learning?

• "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year."

• "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year."

• "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month."

• "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. Which condition is the nurse trying to prevent in this client?

• hypothermia

• heatstroke

• hyperthermia

• frostbite

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. Which could be the possible reason for this sound?

• Inflammation of the pleura

• Muscular spasms in the larger airways

• Sudden reinflation of groups of alveoli

• High velocity airflow through an obstructed airway

Which are the benefits of using standard formal nursing diagnostic statements? Select all that apply. One, some, or all responses may be correct.

• Fosters development of nursing knowledge

• Allows nurses to communicate with the client

• Provides precise definition of the client’s problem

• Distinguishes the nurse’s role from that of other care providers

• Enables the primary health care provider to deliver effective health care