Nursing 102 Final

Which of the following is a barrier to health promotion?

where is posterior tibial pulse?

Where is the point of maximal impulse (PMI) located?

Which nursing action demonstrates cultural competence when addressing spirituality?

where should the nurse place the stethoscope to auscultate the client's apical pulse

auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. this is what

A nurse is assessing a preschooler. Which of the following should indicate to the nurse a need for speech therapy(SATA)

Which of the following is an example of primary prevention?

AP reports vital signs: temp. 98.8°F , PR: 92/min, RR: 18/min, and BP 98/58 mm Hg. the nurse should take which again

A patient says, “I’m not ready to quit smoking.” What stage of change are they in?

A nurse asks a patient to close their eyes and identify an object placed in their hand. What is the nurse assessing?

caring for a newborn & auscultate an apical heart rate of 130/min. Which of the following actions should the nurse take

A school nurse is assessing a child for pediculosis capitis, which should the nurse recognize as an indication of this?

client w/ COPD says, "I can feel the congestion in my lungs, I cough a lot but can't get anything up." The client should

When assessing for scoliosis, the nurse should ask the patient to:

A patient with cancer states, “I believe this is a test from God.” How should the nurse respond?

A nurse bundles care by addressing pain, spiritual needs, and grief. This reflects which nursing approach?

A nurse provides quiet time and dim lighting for a patient after prayer. What concept is being supported?

Which of the following is a modifiable factor that influences adherence?

at a prenatal clinic is completing a skin assessment of client who is in the 2nd trimester. what are expected findings

A nurse is assessing for the Babinski reflex in an adult. What is a normal response?

assessing a client w/ L femoral cardiac angiography. where do you palpate to assess the distal pulse on affected side

a client has lost 25lbs in 3 months and weighs 88lbs but thinks she is fat. what should be the first priority?

Which of the following is an expected finding in a normal lymph node assessment?

What is the priority assessment after a patient reports leg numbness following a cast application?

caring for a client who has a urinary cath and notes blood-tinged urine in the cath bag. what urinary problem is this

What is the first step in developing a patient teaching plan?

assessing a client's radial pulse and determines that the pulse is irregular. what action should the nurse take

a charge nurse is observing a nurse auscultating a client's bowel sounds. which action calls for intervention

assessing a client who has a score of 6 on the Glasgow Coma Scale. what should the nurse expect as an outcome

Which cranial nerve is being tested when a patient sticks out their tongue and moves it side to side?

What condition is indicated by rebound tenderness in the right lower quadrant?

A nurse hears crackles during auscultation of the lungs. What might this indicate?

Which action by the nurse best supports long-term adherence?

A patient asks if a nurse can pray with them. What is the nurse’s best response?

Which cranial nerve is responsible for pupil constriction and eye movement?

What is the purpose of transillumination during a sinus exam?

A patient is unable to move their tongue side to side. This suggests impairment of which cranial nerve?

Which site is preferred for IM injections in adults?

What is the purpose of the Z-track method during IM administration?

listening to lung sounds and finds crackles in the left lower lobe. what should the nurse do next

Which part of the brain controls coordination and balance?

nurse is ready to insert an indwelling urinary catheter for a female client. what instruction should the nurse give

What is a normal finding when assessing muscle strength?

A nurse is supporting a patient in the bargaining stage of grief. Which statement reflects this stage?

A nurse is preparing to perform an ABD assessment on a child, what order would this be preformed in?

a nurse is caring for an older adult who had a stroke and unable to move. the nurse should monitor for what

How does spirituality connect with the concept of coping in nursing care?

assessing a client who is postoperative and has anemia due to excess blood loss following surgery. what is expected

Which of the following is a tertiary prevention strategy?

a nurse removes an indwelling urinary cath that a client had for 2 days, nurse should assess for which expected outcome

A patient who has started exercising 3 times a week is in which stage of behavior change?

caring for a 4-year-old child who is resistant to taking medication. what should the nurse do

What is the normal range for an adult resting heart rate?

Which structure is examined during an ophthalmoscopic exam?

Which term describes a joint that moves beyond the normal range of motion?

A nurse is caring for a terminally ill patient who requests a visit from a spiritual advisor. What should the nurse do?

Which of the following is most important to assess before administering parenteral morphine?

A nurse asks a patient to dorsiflex and plantarflex their foot. What is the nurse assessing?

Which breath sound is expected over the trachea?

A nurse observes that a patient has not been following a low-sodium diet. What is the priority action?

The nurse teaches parents how to prevent accidental poisoning. What type of education is this?

Which nursing intervention best supports intrinsic motivation?

A nurse is preparing to administer heparin subcutaneously. Which site is most appropriate?

planning care for an adolescent who has scoliosis and requires surgical intervention. what is expected by an adolescent

Which behavior is a normal finding during the grieving process?

Which finding would the nurse report immediately in a post-op hip replacement patient?

Which nursing intervention is most appropriate for a grieving family immediately after a sudden death?

What is the term for difficulty breathing when lying flat?

Which concept best aligns with spiritual distress in nursing?

The Glasgow Coma Scale (GCS) is used to assess what?

The nurse teaches a patient to perform breast self-exams. This is an example of:

using motivational interviewing w/ a patient who's ambivalent about quitting smoking. Which response is right?

During a HEENT assessment, the nurse notes a patient has nystagmus. What does this refer to?

A nurse is educating a patient uses spiritual practices like meditation. How is this incorporated into their care plan?

assessing for cyanosis in a client who has dark skin what site should the nurse examine to identify cyanosis

a nurse caring for an infant who has been vomiting for 2 days, the nurse recognizes which as an indicator of fluid loss?

What angle is used for an intramuscular (IM) injection?

Which statement by the patient indicates successful patient teaching?

Teaching older adults should focus on:

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Which should the nurse assess

Which factor most likely improves a patient’s adherence to a health plan?

preparing to instill ear drops to a 3-year-old child. Which of the following techniques should the nurse use?

What is the highest possible score on the Glasgow Coma Scale?

evaluating client who had a cardiac catheterization w/ L antecubital insertion site. what pulse should the nurse palpate

Which finding is considered most concerning during abdominal palpation?

Where is the aortic valve best auscultated?

A nurse palpates a popping or grinding sound during joint movement. What is this called?

Which finding during a HEENT assessment would require immediate intervention?

assessing a patient’s pupils how should you document a normal finding

trying to measure an O2 and there's edema of both hands and thickened toenails. What site should the nurse try instead

A nurse is trying to increase a patient’s motivation to follow a treatment plan. What is the most effective strategy?

What concept is bundled when a nurse supports a grieving family with prayer and therapeutic presence?

After giving an IM injection in the deltoid, what action is appropriate?

caring for a client who has a urinary cath. Which of the following actions should the nurse take to prevent infection

teaching a parent of a 2-year-old child about safe food choices. what foods should the nurse recommend

A patient whose spouse died last week says, “I feel like I’ll never be happy again.” What is the nurse’s best response?

a nurse is caring for a client who just had ABD surgery. which should indicate that the clients peristalsis is returning

When assessing extraocular movements, which test is most appropriate?

Which question would be most appropriate to ask a patient when assessing for tinnitus?

A patient refuses a life-saving procedure due to religious beliefs. What concept is most directly involved?

assessing for hypoxemia during an asthma attack. what should the nurse expect?

The nurse strokes the lateral side of the foot and notes the toes fan outward in an adult. How should this be documented

Which of the following findings in an adult is considered abnormal?

When performing an otoscopic exam on an adult, how should the nurse position the patient’s ear?

Which question is most appropriate when assessing a patient's mental status?

assessing a client who has postoperative atelectasis and is hypoxic. what should the nurse expect

When assessing deep tendon reflexes, a normal response is documented as:

What is the best way to evaluate whether a patient understands discharge instructions?

assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect

What is a nurse's primary role in health promotion?

Which teaching method is most effective for a patient with low health literacy?

A patient reports numbness and tingling in the hands. What type of assessment is most appropriate?

What assessment finding is most concerning in a patient with shortness of breath?

The nurse asks a patient to smile, frown, and puff out their cheeks. This assesses which cranial nerve?

an older adult client in the home who has bad vision due to a history of glaucoma. Which finding is a safety risk

When checking a patient’s reflexes, the nurse notes no response. How is this documented?

A nurse gives a subcutaneous injection of insulin. What is the correct angle for this administration?

assessing a client’s circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

Which cranial nerve is primarily responsible for vision?

A nurse hears a swishing sound over the heart. What is this called?

What finding would indicate complicated grief in a patient?

a nurse is assessing an older adult with osteoporosis. which of the following spinal deformities should the nurse expect

A patient’s whispered voice test result is poor in one ear. What does this likely indicate?

Which quadrant should be assessed first during abdominal exam?

A patient has pain and limited mobility in the right shoulder. What should the nurse do first?

A nurse asks a patient to walk heel-to-toe in a straight line. What is the purpose of this assessment?

Which of the following findings would require immediate intervention during a neuro exam?

assessing a client who has a urine output of 250 mL in a 24-hr period. what would this be charted as

A positive Romberg test indicates:

What is a normal finding during abdominal auscultation?

when preparing an essential screenings chart by age range when should the nurse add in a scoliosis screening?

A patient says, “I keep forgetting to take my blood pressure meds.” What is the nurse’s best first response?

assessing a client who is African American and has jaundice. what should to nurse inspect for jaundice

A nurse teaching a newly diagnosed diabetic to check blood glucose is focusing on:

A nurse explains that a low-sodium diet may help reduce hypertension. This is an example of:

a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point

A patient reports difficulty hearing low-pitched sounds. Which test should the nurse perform?

What is the correct order of assessment for the abdomen?

Which assessment finding indicates fluid overload?

Why is it important to assess spirituality during admission?

a nurse is reviewing info about HIPPA w/ new nurse.Which statement by the new nurse shows a need for further instruction

What is the best position to place a patient in for lung auscultation?