Ch 20

19問 • 3年前

問題一覧

1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?

b. Provide a method for ensuring the patient stays warm.

2. A patient wishes to review his medical record. What response by the nurse is best?

c. “Yes, I can sit with you while you look at it, so you can ask questions.”

3. A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best?

b. Call for another staff member to bring the equipment.

4. A student nurse is preparing to auscultate a patient’s lungs and abdomen. What action by the student leads the instructor to intervene?

c. Student uses the stethoscope bell to listen to bowel sounds.

5. The nurse is assessing a patient’s alcohol intake. What question is most appropriate?

d. “How much alcohol do you drink daily?”

6. The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education?

a. Adolescent who uses a tanning bed.

7. A nurse has assessed a patient’s capillary refill, which was 5 seconds. What action by the nurse is most appropriate?

d. Assess the patient for signs of hypoxia.

8. The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?

b. Healthy eye first to prevent spread of disease

9. A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?

a. Assess the patient for a barrel-chest appearance.

10. The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best to hear the murmur?

c. Auscultate the patient’s chest with a stethoscope.

11. A nurse has conducted an Allen’s test on a patient and the result was 8 seconds. What action by the nurse is best?

a. Document the findings and continue the assessment.

12. A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?

d. Educate the patient on why a massage would be contraindicated.

13. A nurse is told in hand-off report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient’s Glasgow Coma Scale to be?

d. 13

14. A nurse is assessing a patient’s abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?

b. Document the findings in the patient’s chart.

15. A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?

a. Get the provider; assist patient into lithotomy position.

16. A nurse assesses a patient’s lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?

b. Prepare to treat the patient for pneumonia.

17. The nurse is assessing a patient’s cranial nerve III. What technique is best?

b. Shine a light into the patient’s eyes to assess pupil response.

18. A nurse is assessing a patient’s cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best?

a. Ask the patient about recent facial trauma.

19. The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate?

c. Inspect the patient’s nails and surrounding skin.

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4