A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which action should the nurse take next?
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Question 2 of 63
The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant's parents that the Denver II:
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Question 3 of 63
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
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Question 4 of 63
The nurse is performing a neurological assessment and asks the patient to squeeze their hands. Which of the following is being tested?
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Question 5 of 63
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:
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Question 6 of 63
Which statement about the apices of the lungs is true? The apices of the lungs:
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Question 7 of 63
The projections in the nasal cavity that increase the surface area are called the:
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Question 8 of 63
A patient complains of shortness of breath for the past few days. On examination, you note late inspiratory crackles in the lower third of the chest that were not present a week ago. What is the most likely explanation for these?
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Question 9 of 63
Mrs. Jaeger is a 67–year-old who went through menopause at age 55. She has now had some vaginal bleeding. Which of the following should be considered?
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Question 10 of 63
Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination?
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Question 11 of 63
What structures pass through Guyon's canal (ulnar tunnel at the wrist)?
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Question 12 of 63
The nurse is performing a cranial nerve assessment and asks the patient to smile. Which cranial nerve is being tested?
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Question 13 of 63
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
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Question 14 of 63
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
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Question 15 of 63
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
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Question 16 of 63
Which of the following examples includes information recorded in the 'plan' portion of the clinical record?
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Question 17 of 63
Which of the following is not an indication for cold therapy?
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Question 18 of 63
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:
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Question 19 of 63
A nurse assesses a patients eyes by testing the cardinal fields of vision for coordination and alignment. What eye characteristic is being assessed by this process?
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Question 20 of 63
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
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Question 21 of 63
A physical therapist completes an evaluation on a patient with a T12 spinal cord injury. Which functional outcome is MOST likely based on this level of injury?
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Question 22 of 63
Which time of day would we have the lowest temperature reading?
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Question 23 of 63
The nurse is performing a physical assessment and notes that the patient has unilateral leg swelling. What is the most likely diagnosis?
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Question 24 of 63
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed?
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Question 25 of 63
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
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Question 26 of 63
The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
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Question 27 of 63
The nurse has used interpretation regarding a patient's statement or actions. After using this technique, it would be best for the nurse to:
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Question 28 of 63
An adult patient is assessed as having an apical pulse of 140. How would the nurse document this finding?
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Question 29 of 63
You completed the health history and physical examination on your new admission. After completing the assessment phase of the nursing process, the next step includes which of the following?
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Question 30 of 63
The nurse is assessing a patient's lungs and hears a low-pitched gurgling sound during inspiration. What is the most likely cause of this finding?
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Question 31 of 63
A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children?
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Question 32 of 63
A physical therapist evaluates a patient with patellofemoral pain syndrome. Which exercise is MOST appropriate to target the vastus medialis oblique (VMO)?
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Question 33 of 63
The nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS). Which score indicates a moderate head injury?
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Question 34 of 63
The nurse is performing a respiratory assessment and hears crackles in the lower lung fields. What is the most likely cause of this finding?
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Question 35 of 63
A nurse is assessing a client's pain level. Which pain assessment tool is commonly used for self-reporting pain in adults?
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Question 36 of 63
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
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Question 37 of 63
Myofascial pain syndrome is characterized by which of the following?
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Question 38 of 63
A patient is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?
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Question 39 of 63
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
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Question 40 of 63
Which of the following best represents information documented in the 'review of systems'?
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Question 41 of 63
A physical therapist assesses a patient's perception of pain using a visual analog scale (VAS). What type of data does the VAS provide?
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Question 42 of 63
Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?
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Question 43 of 63
The nurse is assessing a patient for signs of dehydration. Which finding is consistent with dehydration?
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Question 44 of 63
Of the following values, which value would be considered prehypertension?
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Question 45 of 63
The nurse is performing a general survey. Which action is a component of the general survey?
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Question 46 of 63
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
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Question 47 of 63
Which is the most effective pattern of palpation for breast cancer?
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Question 48 of 63
The direction of blood flow through the heart is best described by which of these?
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Question 49 of 63
Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?
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Question 50 of 63
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
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Question 51 of 63
What is the primary purpose of performing light palpation during an abdominal examination?
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Question 52 of 63
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
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Question 53 of 63
All of the following muscles involved in wrist and finger flexion receive innervation from the median nerve except:
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Question 54 of 63
A heart rate measurement, or pulse, can be taken at which pulse point?
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Question 55 of 63
During a neurological assessment, the nurse asks the patient to touch their nose with their finger and then touch the nurse's finger. Which function is being assessed?
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Question 56 of 63
A physical therapist receives a referral for a two-month-old infant diagnosed with osteogenesis imperfecta. After completing the examination, the therapist discusses the physical therapy plan of care with the infant's parents. The PRIMARY goal of therapy is to:
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Question 57 of 63
A nurse is assessing a client's oral temperature using an electronic thermometer. How long should the nurse leave the thermometer in place to obtain an accurate reading?
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Question 58 of 63
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next?
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Question 59 of 63
Which is the proper sequence of examination for the abdomen?
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Question 60 of 63
A 60-year-old woman presents with a complaint of joint pain, particularly in the knees. She reports that the pain is worse with activity and improves with rest. She has a history of obesity. What is the most likely diagnosis?
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Question 61 of 63
The nurse keeps in mind the most important step to prevent microorganism transmission in hospitals is:
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Question 62 of 63
The nursing assistive personnel (NAP) UAP reports that a patient's blood pressure is 150/95 mmHg, pulse rate is 98 beats per minute, RR is 20, O2 sat is 98%. What is the pulse pressure?
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Question 63 of 63
Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from phase I to phase V.
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