2. A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the

NUR 133

• The nurse is performing an abdominal assessment on a client. The nurse determines that

which finding should be reported to the primary health care provider (PHCP)?

• Absence of a bruit
• Concave, midline umbilicus
• Pulsation between the umbilicus and the pubis
• Bowel sound frequency of 15 sounds per minute

Answer

• Pulsation between the umbilicus and the pubis

• A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the

nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.

• Asks the client to cover 1 eye
• Examiner covers eye opposite to the eye covered by the client.
• Asks the client to report when object is first noted.
• Stands 2 to 3 ft (60 to 90 cm) in front of client and faces the client.
• The examiner brings in an object gradually from periphery

Answer

B,C,E,A,D

• The clinic nurse prepares to perform a focused assessment on a client who is complaining of

symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

• Auscultating lung sounds
• Obtaining the client's temperature
• Assessing the strength of peripheral pulses
• Obtaining information about the client's respirations.
• Performing a musculoskeletal and neurological examination
• Asking the client about a family history of any illness or disease

Answer A,B,D

• A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring

for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

• Near the lateral 12th rib
• Just under the left clavicle 1 / 2

• In the fifth intercostal space
• Posteriorly under the left scapula

Answer B

• The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How

should the nurse best determine the presence of erythema?

• Assess for drainage from the wound.
• Assess for redness around the wound edges.
• Palpate for swelling around the wound edges.
• Palpate for increased skin temperature around the wound edges.

Answer D

• While performing a cardiac assessment on a client with an incompetent heart valve, the

nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

• Lub-dub sounds
• Scratchy, leathery heart noise
• A blowing or swooshing noise
• Abrupt, high-pitched snapping noise

Answer B

• The nurse is setting up the physical environment for an interview with a client and plans to

obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply

• Set the room temperature at a comfortable level.
• Remove distracting objects from the interviewing area.
• Place a chair for the client across from the nurse's desk.
• Ensure comfortable seating at eye level for the client and nurse.
• Provide seating for the client so that the client faces a strong light.
• Ensure that the distance between the client and nurse is at least

• feet (2.1 meters).

Answer A,B,D

• The registered nurse (RN) is educating a new RN on how to interpret vision tests using a
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