Fundamentals Of Nursing Practice Trivia - 1

1. A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

Level of consciousness (LOC)

Memory

Personality changes

Intellectual ability

2. The nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?

Collects data

Formulates nursing diagnoses

Develops a care plan

Writes client outcomes

3. When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?

Painful skin that is swollen and pale in color

Cold, red skin

Small, localized blackened area of skin

Red, swollen skin with inflammation spreading to surrounding tissues

4. Which pulse should the nurse palpate during rapid assessment of an unconscious adult?

Radial

Brachial

Femoral

Carotid

5. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

Radial

Apical

Carotid

Brachial

6. The nurse is assessing a postoperative client. Which of the following should the nurse document as subjective data?

Vital signs

Laboratory test results

Client's description of pain

Electrocardiographic (ECG) waveforms

7. The nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

Marital status

Cultural influences

Financial resources

Community involvement

8. The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

39° C

47° C

38.9° C

40.1° C

9. When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

Flat, nonpalpable, and colored

Solid, elevated, and circumscribed

Circumscribed, elevated, and filled with serous fluid

Elevated, pus-filled, and circumscribed

10. The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?

"I haven't been able to eat anything solid for the past 2 days."

"I've never had surgery before."

"I had an operation 2 years ago, and I don't want to have another one."

"I've cut my smoking down from two packs to one pack a day."

11. Which of the following factors are major components of a client's general background drug history?

Allergies and socioeconomic status

Urine output and allergies

Gastric reflex and age

Bowel habits and allergies

12. The nurse is assessing a client's abdomen. Which examination technique should the nurse use first?

Auscultation

Inspection

Percussion

Palpation

13. During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data?

Subjective

Objective

Secondary source

Medical

14. When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?

To identify genetic and familial health problems

To identify previously undetected diseases and disorders

To identify the client's reason for seeking care

To identify the client's chronic health problems

15. The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

Encourage a high-calorie, high-protein diet.

Restrict fluids to 1,500 ml per day.

Limit salt intake to 2 g per day.

Encourage foods high in vitamin B.

16. All of the following components may be part of a client's medical record. Which one is the major source of subjective data about the client's health status?

Health history

Physical findings

Laboratory test results

Radiologic findings

17. At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

Check to see that the chest X-ray was done yesterday as ordered.

Check the serum electrolyte levels and complete blood count (CBC).

Notify the physician immediately of these findings.

Sign the preoperative checklist for this client.

18. To evaluate a client's cerebellar function, the nurse should ask:

"Do you have any problems with balance?"

"Do you have any difficulty speaking?"

"Do you have any trouble swallowing food or fluids?"

"Have you noticed any changes in muscle strength?"

19. Which of the following is the most common source of airway obstruction in an unconscious victim?

A foreign object

Saliva or mucus

The tongue

Edema

20. The nurse plans to obtain client information from a primary source. Which is a primary information source?

A family member

The physician

The client

Previous medical records

21. After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

A respiratory rate of 24 breaths/minute with accessory muscle use

Effective breathing at a rate of 16 breaths/minute through the established airway

Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds

Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

22. A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?

Auscultation, percussion, and palpation

Palpation, percussion, and auscultation

Percussion, palpation, and auscultation

Palpation, auscultation, and percussion

23. Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should

Insert an oral airway.

Withhold food and fluids.

Position the client on his side.

Introduce a nasogastric (NG) tube.

24. The nurse conducts a test for the Romberg's sign. What is the correct procedure for this test?

Instruct the client to walk across the room on the heels and to return walking on the toes.

25. The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands?

On the bridge of the nose

Below the eyebrows

Below the cheekbones

Over the temporal area

26. A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:

"Are you having pain?"

"Is the pain constant?"

"Is the pain sharp?"

"What does the pain feel like?"

27. The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

Infection

Dehiscence

Hemorrhage

Evisceration

28. To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?

Skin turgor

Hydration

Organs

Temperature

29. The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Prolonged half-life

Potential for drug dependence

Potential for hepatotoxicity

30. The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

Progressively deeper breaths followed by shallower breaths with apneic periods.

Rapid, deep breaths with abrupt pauses between each breath.

Rapid, deep breaths and irregular breathing without pauses.

Shallow breaths with an increased respiratory rate.

31. A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

Shortening it.

Talking in a loud voice.

Addressing the client by the first name.

Allowing extra time for the assessment.

32. A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time?

Documenting that the client is resting quietly and denies pain

Calling a family member to obtain information about the client

Giving the client the prescribed as-needed pain medication

Checking vital signs and assessing for nonverbal indications of pain

33. Which statement regarding heart sounds is correct?

S1 and S2 sound equally loud over the entire cardiac area.

S1 and S2 sound fainter at the apex.

S1 and S2 sound fainter at the base.

S1 is loudest at the apex, and S2 is loudest at the base.

34. During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?

Auscultation

Inspection

Palpation

Percussion

35. When should the nurse check a client for rebound tenderness?

Near the beginning of the examination

Before doing anything else

Anytime during the examination

At the end of the examination

36. The nurse correctly identifies which items as belonging to the dorsal cavity?

Mediastinum

Mouth

Vertebral canal

Reproductive organs

37. The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

A rub occurs during expiration only and produces a light, popping, musical noise.

A rub occurs during inspiration only and may be heard anywhere.

A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

A rub occurs during inspiration only and clears with coughing.

38. To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

Have the client lie down while taking his blood pressure.

Inflate the cuff to at least 200 mm Hg.

Take blood pressure readings in both arms.

Inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

NURSING PROCESS STEP: Assessment

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Basic care and comfort

COGNITIVE LEVEL: Knowledge

Explanation

NURSING PROCESS STEP: Assessment

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Basic care and comfort

COGNITIVE LEVEL: Knowledge

39. When percussing a client's chest, the nurse should identify which sound as a normal finding?

Hyperresonance

Tympany

Resonance

Dullness

40. Which plane divides the body longitudinally into anterior and posterior regions?

Frontal plane

Sagittal plane

Midsagittal plane

Transverse plane

41. When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?

Constriction and divergence

Dilation and convergence

Constriction and convergence

Dilation and divergence

42. When palpating a client's body to detect warmth, the nurse should use which part of the hand?

Fingertips

Finger pads

Back (dorsal surface)

Ulnar surface

43. The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client took small steps at a rate of 40 to 50 per minute.

The client reported feeling dizzy and weak and perspired profusely.

The client's head was down, gaze was cast down, and toes were pointed outward.

The client's pulse and respiratory rates increased moderately during ambulation.

44. Tachycardia can result from:

Vagal stimulation.

Vomiting, anger, or suctioning.

Fear, pain, or anger.

Stress, pain, or vomiting.

45. An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:

Distended neck veins.

Hypothermia.

Hypertension.

Tachycardia.

46. The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

Coma or seizures.

Sunken eyeballs and poor skin turgor.

Increased heart rate with hypotension.

Thirst or confusion.

47. Hyperactive bowel sounds can result from all of the following except:

Hunger.

Paralytic ileus.

Intestinal obstruction.

Diarrhea.

48. The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging change is:

Cloudy vision.

Incontinence.

Diminished reflexes.

Tremors.

49. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:

Overhydration causes the skin to tent.

Dehydration causes the skin to appear edematous and spongy.

Inelastic skin turgor is a normal part of aging.

Normal skin turgor is moist and boggy.

50. The nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client's ear by pulling the:

Lobule down and forward.

Helix up and back.

Helix up and forward.

Lobule down and back.

51. A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

Pustules

Papule

Plaque

Vesicles

52. The nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

Have the client inhale during auscultation.

Palpate the radial artery during auscultation.

Use the bell of the stethoscope.

Use the diaphragm of the stethoscope.

53. Which descriptions are true about crackles?

They're grating sounds.

They're high-pitched, musical squeaks.

They're low-pitched noises that sound like snoring.

They may be fine, medium, or coarse.

54. When examining a client with abdominal pain, the nurse should assess:

Any quadrant first.

The symptomatic quadrant first.

The symptomatic quadrant last.

The symptomatic quadrant either second or third.

55. The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

Whispered voice test

Weber's test

Watch tick test

Rinne test

56. The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?

"The stoma should appear dark and have a bluish hue."

"At first, the stoma may bleed slightly when touched."

"The stoma should remain swollen distal to the abdomen."

"A burning sensation under the stoma faceplate is normal."

57. The nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:

Having more frequent aches and pains.

Failing eyesight, especially close vision.

Increasing loss of muscle tone.

Accepting limitations while developing assets.

58. To evaluate a client's posterior tibial pulse, where should the nurse palpate?

Medially in the antecubital space

Midway between the superior iliac spine and symphysis pubis

On the inner aspect of the ankle, below the medial malleolus

Along the top of the foot, over the instep

59. The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

Dullness over the liver

Bowel sounds occurring every 10 seconds

Shifting dullness over the abdomen

Vascular sounds heard over the renal arteries

60. The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?

Assess extremities, ensuring that the extremity with the splint feels cooler than the unsplinted extremities

Move the client's fingers or toes to test movement

Compare the capillary refill of each extremity, making sure it's the same bilaterally

Be aware that edema and pulse checks aren't part of the neurovascular assessment

61. A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?

Using deep palpation

Assessing the painful area last

Assessing the painful area first

Checking for warmth in the painful area

62. Which of the following sentences correctly describes the anatomic position?

The body is supine.

Arms are elevated at shoulder level.

Palms are turned forward.

The body is facing backward.

63. When performing an abdominal assessment, the nurse should follow which examination sequence?

Inspection, auscultation, percussion, and palpation

Inspection, auscultation, palpation, and percussion

Inspection, percussion, palpation, and auscultation

Inspection, palpation, percussion, and auscultation

64. A 76-year-old client with no debilitating conditions belongs to which geriatric population?

Young-old

Middle-old

Old-old

Frail elderly

65. The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release

Using light palpation, noting any tenderness over an area

Using deep ballottement, noting any tenderness over an area

Pressing firmly with one hand, releasing pressure while maintaining fingertip contact with the skin, and noting tenderness on release

66. The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

67. Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is most likely to detect:

Pallor and coolness of the left foot.

A decrease in the left pedal pulse.

Loss of hair on the lower portion of the left leg.

Left calf circumference 1" (2.5 cm) larger than the right.

68. When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:

Opening of the mitral and tricuspid valves.

Closing of the mitral and tricuspid valves.

Opening of the aortic and pulmonic valves.

Closing of the aortic and pulmonic valves.

69. When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse is using which of the following?

Developmental anatomy

Applied anatomy

Regional anatomy

Descriptive anatomy

70. The nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

The client can read the entire vision chart at 40′ (12 m).

The client can read from 20′ (6 m) what a person with normal vision can read at 40′.

The client can read the vision chart from 20′ with the right eye and from 40′ with the left eye.

The client can read at 30′ (9 m) what a person with normal vision can read at 40′.

71. When routinely evaluating a geriatric client for any atypical signs or symptoms, the nurse should remember that:

Aging can reduce the body's ability to regulate body temperature.

Aging can increase pain perception.

Anesthesia usually causes psychotic behavior postoperatively in a geriatric client.

The risk of developing emphysema is highest in elderly people.

72. A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

Frontal

Occipital

Parietal

Temporal

73. When palpating the bladder of an adult client, the nurse should identify which finding as normal?

A soft, smooth bladder

A hard, rough bladder

A nonpalpable bladder

A palpable bladder located 3" to 5" (7.5 to 12.7 cm) above the symphysis pubis

74. Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client?

Because the nurse's touch may calm the child

Because the child may cry as the assessment proceeds, making auscultation difficult

Because the nurse's touch may frighten the child

Because the nurse's hand or stethoscope may feel cold, making the child recoil

75. The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called:

The pulse pressure.

The pulse deficit.

The pulse rhythm.

Pulsus regularis.

76. The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

The bell detects high-pitched sounds best.

The diaphragm detects high-pitched sounds best.

The bell detects thrills best.

The diaphragm detects low-pitched sounds best.

77. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

Restlessness

Pale, warm, dry skin

Heart rate of 110 beats/minute

Urine output of 30 ml/hour

78. Why shouldn't the nurse palpate both carotid arteries at one time?

The pulse can't be assessed accurately unless the arteries are palpated one at a time.

It may cause transient hypertension.

It may cause severe bradycardia.

It may cause severe tachycardia.

79. When assessing a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:

Increased coronary artery blood flow.

Decreased posterior thoracic curve.

Decreased peripheral resistance.

Delayed gastric emptying.

80. A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

To obtain a heart rate that isn't affected by medication

To eliminate interference from the jerky movements of chorea

To ensure that the child can't consciously raise or lower the heart rate

To compensate for the effects of activity on the heart rate

81. The nurse prepares to perform light palpation. How is light palpation performed?

By indenting the skin ½" to ¾" (1.3 to 1.9 cm)

By indenting the skin 1" to 2" (2.5 to 5 cm)

By indenting the skin 1", using both hands

By indenting the skin 1" and then releasing the pressure quickly

82. The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference

Measuring the arm about 2" (5 cm) above the antecubital space

Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

Using a bladder that is 6" (15 cm) long.

83. A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?

Intradermal injection is less painful.

Intradermal drugs are easier to administer.

Intradermal drugs diffuse more rapidly.

Intradermal drugs diffuse more slowly.

84. Why should an infant be quiet and seated upright when the nurse assesses his fontanels?

The mother will have less trouble holding a quiet, upright infant.

Lying down can cause the fontanels to recede, making assessment more difficult.

The infant can breathe more easily when sitting up.

Lying down and crying can cause the fontanels to bulge.

85. The nurse is assessing a client's pulse. Which pulse feature should the nurse document?

Timing in the cycle

Amplitude

Pitch

Intensity

86. To help assess a client's cerebral function, the nurse should ask:

"Have you noticed a change in your memory?"

"Have you noticed a change in your muscle strength?"

"Have you had any coordination problems?"

"Have you had any problems with your eyes?"

87. A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this nurse?

Refuse to float to ICU.

Notify the nursing supervisor that she feels unqualified and untrained for the assignment.

Go to ICU and take a total client assignment; ask the critical care nurses for assistance when necessary.

88. A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

Barely visible outside the tonsillar pillar.

Halfway between the tonsillar pillar and the uvula.

Touching the uvula.

Touching each other.

89. The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?

"When did the rash start?"

"Are you allergic to any medications, foods, or pollen?"

"How old are you?"

"What have you been using to treat the rash?"

"Have you recently traveled outside the country?"

"Do you smoke cigarettes or drink alcohol?"

Submit

90. The nurse can auscultate for heart sounds more easily if the client is:

Supine.

On his right side.

Holding his breath.

Leaning forward.

91. Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

Keep the client warm.

Maintain room temperature at 78° F (25.6° C).

Keep the client uncovered.

Match the room temperature with the client's body temperature.

92. The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:

Fingertips.

Ulnar surface of the hand.

Dorsal surface of the hand.

Finger pads.

93. A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade on the front of the tongue and ask the client to say "ah."

Place a tongue blade lightly on the posterior aspect of the tongue.

Place a tongue blade on the middle of the tongue and ask the client to cough.

Place a tongue blade on the uvula.

94. When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

The history of the present problem, medications, review of systems, and recent major operations.

The history of the present problem, allergies, medications, and recent major operations.

The history of the present problem, medications, family history, psychosocial history, and review of systems.

The history of the present problem, allergies, medications, review of systems, and recent major operations.

95. When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:

Decreased bowel motility.

Increased bowel motility.

Nothing abnormal.

Abdominal cramping.

96. A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:

Higher systolic blood pressure reading.

Higher diastolic blood pressure reading.

Lower systolic blood pressure reading.

Lower diastolic blood pressure reading.

97. The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?