NCLEX RN NURSING HEALTH

NCLEX RN NURSING HEALTH

ASSESSMENT AND PAIN EXAM

• Mr. Teban is a 73-year old patient diagnosed with pneumonia. Which data would be

of greatest concern to the nurse when completing the nursing assessment of the patient?

• Alert and oriented to date, time, and place
• Buccal cyanosis and capillary refill greater than 3 seconds
• Clear breath sounds and nonproductive cough
• Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3 Correct - 1.

Answer: B. Buccal cyanosis and capillary refill greater than 3 seconds

Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.

• During the nursing assessment, which data represent information concerning health

beliefs?

• Family role and relationship patterns
• Educational level and financial status
• Promotive, preventive, and restorative health practices
• Use of prescribed and over-the-counter medications Correct - 2. Answer: C.

Promotive, preventive, and restorative health practices

The health-beliefs assessment includes expectations of health care; promotive, preventive, and restorative practices, such as breast self-examination, testicular examination, and seat-belt use; and how the client perceives illness. Use of medications provides information about the client's personal habits. Educational level, financial status, and family role and relationship patterns represent information associated with role and relationship patterns.

• Nurse Patrick is acquiring information from a client in the emergency department.

Which is an example of biographic information that may be obtained during a health history?

• The chief complaint
• Past health status
• History immunizations
• Location of an advance directive Correct - 3. Answer: D. Location of an advance

directive

Biographic information may include name, address, gender, race, occupation, and location of a living will or a durable power of attorney for health care. The chief complaint, past health status, and history of immunizations are part of assessing the client's health and illness patterns.

• John Joseph was scheduled for a physical assessment. When percussing the client's

chest, the nurse would expect to find which assessment data as a normal sign over his lungs?

• Dullness
• Resonance
• Hyperresonance

D. Tympany Correct - 4. Answer: B. Resonance

Normally, when percussing a client's chest, percussion over the lungs reveals resonance, a hollow or loud, low-pitched sound of long duration. Tympany is typically heard on percussion over such areas as a gastric air bubble or the intestine. Dullness is typically heard on percussion of solid organs, such as the liver or areas of consolidation.Hyperresonance would be evidenced by percussion over areas of overinflation such as an emphysematous lungs.

• Matteo is diagnosed with dehydration and underwent series of tests. Which

laboratory result would warrant immediate intervention by the nurse?

• Serum sodium level of 138 mEq/L
• Serum potassium level of 3.1 mEq/L
• Serum glucose level of 120 mg/dl
• Serum creatinine level of 0.6 mg/100 ml Correct - 5. Answer: B. Serum potassium

level of 3.1 mEq/L

A normal potassium level is 3.5 to 5.5 mEq/L. A normal sodium level is 135 to 145 mEq/L, a normal nonfasting glucose level is 85 to 140 mg/dl, and a normal creatinine level is 0.2 to 0.8 mg/100 ml.

• During an otoscopic examination, which action should be avoided to prevent the

client from discomfort and injury?

• Tipping the client's head away from the examiner and pulling the ear up and back
• Inserting the otoscope inferiorly into the distal portion of the external canal
• Inserting the otoscope superiorly into the proximal two-thirds of the external canal
• Bracing the examiner's hand against the client's head Correct - 6. Answer: C.

Inserting the otoscope superiorly into the proximal two-thirds of the external canal

In the superior position, the speculum of the otoscope is nearest the tympanic membrane, and the most sensitive portion of the external canal is the proximal two- thirds. It is important to avoid these structures during the examination. Tipping the

client's head away from the examiner, pulling the ear up and back, inserting the otoscope inferiorly, and bracing the examiner's hand against the client's head are all appropriate techniques used during an otoscopic examination.

• When assessing the lower extremities for arterial function, which intervention should

the nurse perform?

• Assessing the medial malleoli for pitting edema
• Performing Allen's test
• Assessing the Homans' sign
• Palpating the pedal pulses Correct - 7. Answer: D. Palpating the pedal pulses

Palpating the client's pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Allen's test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Homans' sign is used to evaluate the possibility of deep vein thrombosis.

• Newly hired nurse Liza is excited to perform her very first physical assessment with a

19-year-old client. Which assessment examination requires Liza to wear gloves?

• Breast
• Integumentary
• Ophthalmic

D. Oral Correct - 8. Answer: D. Oral

Gloves should be worn any time there is a risk of exposure to the client's blood or body fluids. Oral, rectal, and genital examinations require gloves because they involve contact with body fluids. Ophthalmic, breast, or integumentary examinations normally do not involve contact with the client's body fluids and do not require the nurse to wear gloves for protection. However, if there are areas of skin breakdown or drainage, gloves should be used.

• Nurse Renor is about to perform Romberg's test to Pierro. To ensure the latter's

safety, which intervention should nurse Renor implement?

• Allowing the client to keep his eyes open
• Having the client hold on to furniture
• Letting the client spread his feet apart
• Standing close to provide support Correct - 9. Answer: D. Standing close to

provide support

During Romberg's test, the client is asked to stand with feet together and eyes shut and still maintain balance with the minimum of sway. If the client loses his balance, the nurse standing close to provide support, such as having an arm close around his

shoulder, can prevent a fall. Allowing the client to keep his eyes open, spread his feet apart, or hang on to a piece of furniture interferes with the proper execution of the test and yields invalid results.

• Physical assessment is being performed to Geoff by Nurse Tine. During the

abdominal examination, Tine should perform the four physical examination techniques in which sequence?

• Auscultation immediately after inspection and then percussion and palpation
• Percussion, followed by inspection, auscultation, and palpation
• Palpation of tender areas first and then inspection, percussion, and auscultation
• Inspection and then palpation, percussion, and auscultation Correct - 10. Answer:
• Auscultation immediately after inspection and then percussion and palpation

With an abdominal assessment, auscultation always is performed before percussion and palpation because any abdominal manipulation, such as from palpation or percussion, can alter bowel sounds. Percussion should never precede inspection or auscultation, and any tender or painful areas should be palpated last.

• Which assessment data should the nurse include when obtaining a review of body

systems

• Brief statement about what brought the client to the health care provider
• Client complaints of chest pain, dyspnea, or abdominal pain
• Information about the client's sexual performance and preference
• The client's name, address, age, and phone number Correct - 11. Answer: B.

Client complaints of chest pain, dyspnea, or abdominal pain

Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client's perceptions of major body system functions, including cardiac, respiratory, and abdominal. The client's name, address, age, and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client's sexual performance and preference addresses past health status.

• Tywin has come to the nursing clinic for a comprehensive health assessment.

Which statement would be the best way to end the history interview?

• "What brought you to the clinic today?"
• "Would you describe your overall health as good?"
• "Do you understand what is happening?"
• "Is there anything else you would like to tell me?" Correct - 12. Answer: D. "Is

there anything else you would like to tell me?"