(Test Bank) Nclex Practice Testbank-Interventions Nursing Practice Questions & Answers With Rationales 2020/2021

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Question 1: (see full question)When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order You selected: Inspection, auscultation, percussion, palpation Correct Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 Question 2: (see full question)The nurse in post-anesthesia recovery (PAR) is caring for a 27- year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain, the client continues to report abdominal discomfort and requests more morphine. Which action by the nurse is best? You selected: Observe the abdomen for distention and rigidity. Correct Explanation: Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment by the nurse to rule out peritonitis or internal bleeding by observing the abdomen for distention and rigidity. Administration of more morphine could mask the cause of the abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat to the abdomen would increase blood flow to the area and potentially increase pain or internal bleeding. Positioning the client in a knees- flexed position may relieve the discomfort, but an assessment is needed before any intervention is implemented. ( less)NCLEX Practice TestBank -Interventions Nursing Page 1 Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 Question 3: (see full question)The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? You selected: Palpation Correct Explanation: The thyroid gland is assessed by palpation, although it is not normally palpable in some patients. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648. Chapter 25: Health Assessment - Page 647 Question 4: (see full question)The nurse is asking admission interview questions and the client has explained the reason for seeking care. Which of the following is the most appropriate way to document the response? You selected: Client describes shortness of breath and increased sputum production. Incorrect Correct response: Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."Explanation: The client's reason for seeking care should always be stated in the client's own words. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628 Question 5: (see full question)The nurse in the emergency department observes a client experiencing a generalized tonic–clonic seizure. What is the priority intervention for the nurse to take? You selected: Assess and maintain the client's airway. Correct Explanation: Risk for aspiration is a concern during a seizure because the client will have copious oral secretions that will need to be suctioned and allowed to drain out of the mouth. The nurse should assess the client's airway and maintain it by placing the client in a side-lying position, which will allow the oral secretions to drain from his mouth and not accumulate in his throat and compromise the airway. It is contraindicated to place anything in the mouth of a person who is actively convulsing. Reorienting the client and documenting the seizure are important actions after the postictal phase, but client safety is the priority intervention during a seizure. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 Question 6: (see full question)The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurseassesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following? You selected: Erosion Incorrect Correct response: Fissure Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4. Chapter 25: Health Assessment - Page 641 Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 654, Box 25-5. Chapter 25: Health Assessment - Page 654 Question 7: (see full question)The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? You selected: Each lub-dub is one beat. Correct Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate. (less) Question 8: (see full question)Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor? You selected: Percussion Correct Explanation: Percussion is the act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The location, shape, size, and density of organs or tumors are assessed with this method. Observation is visually looking at an object. The characteristics that can be determined about a tumor by palpation include shape, size, consistency, surface, mobility, tenderness, and pulsatile. ( less) Reference: Taylor, C.R. Fundamentals of Nursing , 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 635 Question 9: (see full question)The nurse is palpating the skin of a 30-year old patient and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? You selected: Assess the patient for dehydration. CorrectExplanation: Turgor is the fullness or elasticity of the skin. The patient should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the patient is dehydrated, the skin’s elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease, nor cystic fibrosis. ( less) Reference: Taylor, C.R. Fundamentals of Nursing , 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 639 Question 10: (see full question)The nurse is using a bed scale to weigh a patient, and the patient becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? You selected: Enlist the help of another nurse to hold the patient steady during the procedure. Incorrect Correct response: Stop lifting the patient and reassess him or her. Explanation: The nurse should stop lifting the patient and reassure him or her. If the patient continues to be agitated, the nurse lowers the patient back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the patient may result in injury to the patient. An order for sedation would only be requested if it was absolutely necessary to obtain the patient’s weight at this time. Another nurse holding the patient steady does not address the patient’s agitation. ( less) Reference: Taylor, C.R. Fundamentals of Nursing , 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 674Question 11: (see full question)To obtain subjective data about a newly admitted client's sleep pattern, the nurse You selected: Asks the client what promotes sleep Correct Explanation: The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 Question 12: (see full question)A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment? You selected: Comprehensive assessment Correct Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 626. Chapter 25: Health Assessment - Page 626 Question 13: (see full question)A 57-year-old male client is admitted to the medical unit with a 3- day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? You selected: Palpation Correct Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659. Chapter 25: Health Assessment - Page 659 Question 14: (see full question)You are assessing a patient's thorax and lungs. Which of the following findings would indicate the need for further assessment? You selected: Auscultation of short, high-pitched popping sounds during inspiration Correct Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 Question 15: (see full question)A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment? You selected: Inspection Incorrect Correct response: Auscultation Explanation: Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 632. Chapter 25: Health Assessment - Page 632Question 16: (see full question)The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene? You selected: Palpation of both carotid arteries at the same time Correct Explanation: Palpation of both arteries at once can obstruct blood flow to the brain. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 655. Chapter 25: Health Assessment - Page 655 Question 17: (see full question)The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? You selected: Check the client’s ear canals for cerumen. Correct Explanation: Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking to the elderly who are hearing- impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for the elderly. ( less) Reference: Taylor, C. R. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646. Chapter 25: Health Assessment - Page 646 Question 18: (see full question)The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider? You selected: Auscultation of a bruit Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 Question 19: (see full question)A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ... You selected: peripheral pulses. Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 Question 20: (see full question)Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Wheezes Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Question 18: (see full question)The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider? You selected: Auscultation of a bruit Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 Question 19: (see full question)A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ... You selected: peripheral pulses. Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 Question 20: (see full question)Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Wheezes Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Answer KeyQuestion 1: (see full question)The nurse is caring for a client after a stroke that left the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals? You selected:• To restore health Correct Explanation: The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. In the example, the nurse is coordinating care with the other disciplines in an attempt regain some of the strength in the client's right side. This is an example of restoring a client's health. The nurse is not preventing the stroke or promoting health prior to the stroke or facilitating coping with the stroke. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 10. Chapter 1: Introduction to Nursing - Page 10 Question 2: (see full question)A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient? You selected:Facilitating coping Correct Explanation: This patient's care in the coming weeks or months will likely encompass all of the four foundational roles of the nurse. However, because the patient has just recently received bad news and is emotionally distraught, helping the patient cope is an appropriate priority in his immediate care. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing , 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 13. Chapter 1: Introduction to Nursing - Page 13 Question 3: (see full question)The nurse working with an LPN understands which of the following about LPNs?You selected:They may work independently. Incorrect Correct response:They must take a licensure exam. Explanation: Schools for practical nursing programs are located in varied settings. Most programs are 1 year in length. Upon completion of the program, graduates can take the National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work under the direction of a physician or RN to give direct care to clients, focusing on meeting healthcare needs in hospitals, nursing homes, and home health agencies. ( less) Question 4: (see full question)A group of nursing students has attended a presentation about the National Student Nurses' Association (NSNA). Which statement by the group indicates that they have understood the information presented? You selected:The organization provides programs of current professional interest. Correct Explanation: The National Student Nurses' Association provides programs of current professional interest. It is not run by a group of registered nurses, but by nursing students themselves. It is student-funded, not funded by the national government. The Commission on Collegiate Nursing Education, not the National Student Nurses' Association, contributes to the improvement of public health. ( less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 17. Chapter 1: Introduction to Nursing - Page 17 Question 5: (see full question)Which nursing actions demonstrate the aim of nursing to facilitate coping? (Select all that apply.) You selected:• Assisting a patient and his/her family to prepare for death • Teaching a patient and his/her family how to live with diabetes • Providing counseling for the family of a teenager with an eating disorder Correct Explanation: Coping is another important broad aim of nursing. Nurses facilitate client and family coping with altered function, life crisis, and death. Examples of coping would be