A patient was admitted with possible head trauma. The nursing implementation with the highest priority is to

Check for verbal and motor response

To correctly determine the strength of a patients lowerextremities during a neurological exam the nurse asks the patient

Push against his hand with the sole of one foot

An 8 year old patient due for height measurement. for an accurate measurement the child should be asked to stand

With back toward the rod and the feet centered together

The nurse weighing an infant in an outpatient clinic should

Keep one hand hovering over the infant during the weighing procedure

If there is prior authorization for hospitalization require routine admissions The insurance company is responsible for

Office of admitting primary care provider

When performing deep palpations, the nurse should

Use either one or two hands to depress tissue 1.5 to 2 inches

During a health interview an older patient has difficulty remembering info about the health history, the nurse should

Gather information from a family member accompanying the patient

When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be places on the

Fifth intercoastal space, left anterior axillary line

When the nurse discovers that the patients consent for a invasive procedure was transcribed incorrectly the nurse should

Destroy the incorrect form and write a new one correctly

To preform the weber test, the turning fork is struck and placed

In the middle of the forehead and skull

A nurse caring for a patient on bed rest with a history of respiratory health problems should

Auscultate lung sounds at the beginning of a shift

The nurse orienting a new patient to the unit would include

Location of call bell and how to use it

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Questions 17

Answers

1
A patient was admitted with possible head trauma. The nursing implementation with the highest priority is to
Check for verbal and motor response
Monitor intake and output
Auscultate lung and abdominal sounds
Monitor daily weight
2
The nurse lightly palpates the abdomen of a patient during a physical exam on palpation to the right the nurse should
Proceed to percuss the abdomen with a quick snap of the wrist
Continue the examination and have the patient take deep breaths
Palpate the abdominal skin 1.5 to 2 inches to determine pain
Discontinue the examination
3
To correctly determine the strength of a patients lowerextremities during a neurological exam the nurse asks the patient
Push against his hand with the sole of one foot
Stand up independently
Pull both feet up the same
Wiggle the toes of both feet at the same time
4
An 8 year old patient due for height measurement. for an accurate measurement the child should be asked to stand
With back toward the rod and the feet 8 inches apart
With back toward the rod and the feet centered together
With back toward the rod and the feet 6 inches apart
With back toward the rod and the feet 4 inches apart
5
The nurse weighing an infant in an outpatient clinic should
Rest a hand lightly on the infant's abdomen
Place the baby in a prone position
Place a towel on the scale
Keep one hand hovering over the infant during the weighing procedure
6
If there is prior authorization for hospitalization require routine admissions The insurance company is responsible for
Office of admitting primary care provider
Patient primary care provider and admissions department
Admissions department of heath facility
Patient
7
When performing deep palpations, the nurse should
Use one hand and exert pressure to depress tissue
Use either one or two hands to depress tissue 1 inch
use two hands and exert pressure to depress the tissue about 3 to 4 inches
Use either one or two hands to depress tissue 1.5 to 2 inches
8
During a health interview an older patient has difficulty remembering info about the health history, the nurse should
Gather information from a family member accompanying the patient
Omit the interview
Reassure the patient that forgetfulness is normal
Repeat the questions at the end of the visit
9
An older adult American Indian has been admitted to the hospital with abdominal pain. the nuse should
Cultural assessment
Financial history
Literacy assessment
Phycological history
10
When the heart is assessed for the point of maximal impulse (PMI), the stethoscope should be places on the
Second intercoastal space, right midclavicular line
Fifth intercoastal space, left anterior axillary line
Fifth intercoastal space left midclavicular line
Fourth intercoastal space, left sternal border
11
Prior to preparing a female patient for a pelvic exam. the nurse should
Provide a pillow for the head and legs
Encourage her to void
Hand the patient a sheet and allow her to drape herself
Cleanse the external genitalia with soap and water
12
The nurse assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes. the nurse documents
7
10
12
15
13
When the nurse discovers that the patients consent for a invasive procedure was transcribed incorrectly the nurse should
Notify the primary care provider of the error and clarify
Cross out the incorrect information and write erroe then write correct info
Destroy the incorrect form and write a new one correctly
Cross out the entire form but leave it in the medical record as permanent
14
To preform the weber test, the turning fork is struck and placed
At the nape of the neck
In the middle of the forehead and skull
In the middle of the bridge of the nose
Behind the right and then the left ear
15
A nurse records absence of bowel sounds after assessing the abdomen
In each quadrant
In all quadrants
In the two lower quadrants
In the two upper quadrants
16
A nurse caring for a patient on bed rest with a history of respiratory health problems should
Monitor for skin turgor every shift
Auscultate lung sounds at the beginning of a shift
Monitor peripheral pulses once a shift
Auscultate for bowel sounds once a shift
17
The nurse orienting a new patient to the unit would include
Location of call bell and how to use it
Expected cost of the room per day
Times of shift changes
Calling the patient by their first name for less formality

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