5011 multiple choice

Hand hygiene

The most important and basic technique in preventing and controlling transmission of infection in the clinical setting.

Immobilized lump

A lump that does not move when palpated, which may require consulting with a clinical instructor.

Personal protective equipment for MRSA and pneumonia

The nurse should wear gloves, mask, and gown.

Assessment technique used for every body part

Inspection.

Best action to hear bowel sounds

Reduce all environmental noise.

Patient safety before leaving the room

Lower the bed height.

When gloves are not needed

Checking blood pressures at a health fair.

NOT a component of standard precautions

Surgical mask worn within 3 feet of patients.

Braden score documentation for a 62-year-old male

16.

Decreased turgor requires further assessment because

It indicates dehydration.

Request for a trained interpreter

This is the best action before interviewing a client who speaks a different language.

Clubbing of nails is associated with signs of

Hypoxia.

Assessment of CN VIII

Test the patient's hearing for lateralization and bone and air conduction.

Unilateral dilated pupil indicates a problem with which cranial nerve?

CN III.

Importance of nursing health assessment

It helps evaluate health status, risk factors, and educational needs.

Subjective data in health history

Includes symptoms reported by the patient.

Finding with pupillary response during assessment

Suggestive of consensual reaction.

Normal finding when assessing cranial nerves X

Uvula and soft palate rising bilaterally.

Anatomical characteristic of lungs

The right lung has three lobes, whereas the left lung has two lobes.

Cranial nerve assessed by pupil size

Cranial nerve III.

Transmitted voice sounds suggest

Pneumonia.

Glasgow Coma Scale score for withdrawal from painful stimuli

8.

Respiratory pattern with eight breaths per minute

Bradypnea.

Part of the hand for assessing tactile fremitus

Ulnar Surface.

Sentence to assess orientation in neurological exam

Can you tell me where you are right now?

Expected tone during thorax percussion in healthy patients

Resonance.

Grading reflex documentation for diminished left knee reflex

Right knee +2; Left knee +1.

Normal location of point of maximal impulse (PMI)

Left 5th intercostal space 7 to 10 cm lateral to the sternum.

Assessment to measure shoulder joint abduction

Bring your arms out to the side and bring the hands together overhead.

Typical motions associated with the knee joint

Flexion.

Area overlaying the heart and great vessels

Precordium.

Assessment for pitting edema involves

Pressing down on the patient's arm with the tip of the thumb.

Symptom requiring orthopnea description

Difficulty breathing when lying flat.

Muscle strength grading for active movement against gravity

3/5.

Peripheral vascular disease assessment importance

Size, symmetry, and skin colour.

Heart sound associated with the beginning of systole

S1.

Structural difference in child's urethral meatus

Hypospadias.

Tanner Stage 3 penile development description

Penis increased in width; abundant pubic hair but not extending to thighs.

Tenderness over costovertebral angle indicates issues with

Kidney.

Condition where foreskin cannot be replaced over the glans

Paraphimosis.

Correct order of abdominal assessment

Inspection, Auscultation, Percussion, Palpation.

Palpated organ in right upper quadrant assessment

Liver.

Sound expected during abdominal percussion

Tympany.

Abdominal quadrant containing the gallbladder

RUQ.

Technique for assessing abdomen shown in the picture

Light palpation.

Situations requiring soap and water for hand hygiene

Hands visibly soiled with blood or other fluids; exposure to Clostridium difficile.

Assessment of cerebellar function includes

Rapid Alternating Movements, Finger to Nose Testing, Heel to Shin Testing, Gait.

Adjustments before patient examination

Adjusting the bed height, turning off TV, asking the client to reposition.