Question

The nurse percusses the lungs of a client with no lung problems. What is the expected assessment finding?

Answer 1

Correct Answers:

Resonance

Rationale :

🫁Resonance is the expected percussion sound over normal air-filled lung tissue.

🎵Normal lungs contain a mixture of air and tissue, producing a low-pitched, hollow sound.

🩺Percussion helps identify abnormal changes in the amount of air, fluid, or solid tissue beneath the chest wall.

🌬️Therefore, resonant percussion supports the finding of normally aerated lungs.

📌Core Message

Normal lung tissue produces resonance because the lungs normally contain air.

Answer 2

Correct Answers:

Client is alert but confused.

Rationale :

🧠The client is alert because the client is awake, speaking, and expressing a basic need.

🗣️The statement about the daughter suggests confusion regarding the current situation.

🧭Being oriented requires accurate awareness of person, place, time, and situation.

👵A client with dementia can remain awake and responsive while experiencing confusion or impaired orientation.

📌Core Message

A person can be alert while confused, particularly when cognitive impairment such as dementia is present.

Answer 3

Correct Answers:

use of the prescribed antifungal medication.

Rationale :

🍄A thickened, yellow or darkened toenail is characteristic of onychomycosis, a fungal nail infection.

🦶Fungal infections commonly cause nails to become thick, brittle, distorted, and discolored.

💊Treatment frequently involves prescribed topical or systemic antifungal therapy, depending on severity.

🔬The healthcare provider should confirm the diagnosis because prolonged antifungal treatment may be necessary.

📌Core Message

A thick, discolored toenail commonly indicates onychomycosis, which is treated with appropriate antifungal therapy.

Answer 4

Correct Answers:

Assess the dorsalis pedis and posterior tiblal using a doppler.

Rationale :

📡A Doppler ultrasound device can detect peripheral blood flow when a pulse cannot be felt manually.

🩸A nonpalpable pulse does not automatically mean arterial flow is absent.

🔍The nurse should perform further vascular assessment before documenting the pulse as absent.

🚨Failure to detect the pulses even with Doppler would increase concern for significant arterial insufficiency and require prompt escalation.

📌Core Message

When peripheral pulses cannot be palpated, use a Doppler to determine whether arterial blood flow is present.

Answer 5

Correct Answers:

Small greyish-white bodies that are sticking to the student's hair shaft.

Rationale :

🐜Head lice produce nits, which are small eggs firmly attached to individual hair shafts.

🥚Nits commonly appear whitish, gray, or tan and are especially noticeable near the scalp.

🧴Unlike dandruff, nits are firmly adherent and do not brush away easily.

👩‍⚕️Identifying attached nits or live lice supports a diagnosis of pediculosis capitis.

📌Core Message

Head lice infestation is identified by lice or firmly attached nits on the hair shafts.

Answer 6

Correct Answers:

“Look at the wall in the back of the room. Now look at my finger.”

Rationale :

👁️The A in PERRLA represents accommodation.

🔭Accommodation occurs when the eyes change focus from a distant object to a near object.

🎯During accommodation, the pupils normally constrict and the eyes converge when focusing nearby.

🧑‍⚕️Having the client alternate between a distant target and the examiner's finger directly evaluates this near-focus response.

📌Core Message

Accommodation is assessed by observing the eyes while the client changes focus from a distant object to a nearby object.

Answer 7

Correct Answers:

Anticoagulant administration
Obesity
Smoking
Increased abdominal pressure

Rationale :

💉Heparin therapy can increase bleeding and hematoma formation, which can interfere with normal wound healing.

⚖️A BMI of 36 indicates obesity, which is associated with reduced tissue perfusion and increased stress on surgical incisions.

🚬A history of smoking compromises oxygen delivery and tissue perfusion, contributing to delayed healing.

🤧Increased abdominal pressure places mechanical stress on an abdominal incision and can contribute to wound separation or dehiscence.

📌Core Message

Important wound-complication risks include anticoagulation, obesity, smoking, and excessive mechanical pressure on the incision.

Answer 8

Correct Answers:

75

Rationale :

🧮The available solution contains 2 g in 50 mL, while the prescribed dose is 1.5 g.

📐The required volume is calculated as 1.5 ÷ 2 × 50 = 37.5 mL.

⏱️Thirty minutes equals 0.5 hour, which must be used when calculating the hourly pump rate.

💧The infusion rate is therefore 37.5 mL ÷ 0.5 hr = 75 mL/hr.

📌Core Message

The client needs 37.5 mL over 30 minutes, resulting in an IV pump setting of 75 mL/hr.

Answer 9

Correct Answers:

Complete the assessment then report the finding to the health care provider immediately.

Rationale :

🩸Widespread petechiae can indicate thrombocytopenia or another abnormality affecting hemostasis.

👄Petechiae involving the oral mucosa and multiple body areas raise concern for a systemic rather than localized problem.

📋The nurse should complete the immediate assessment to identify additional signs of bleeding or clinical instability.

☎️The findings should then be communicated promptly to the healthcare provider because the client may require urgent laboratory evaluation and treatment.

📌Core Message

Widespread petechiae require prompt medical evaluation because they can signal thrombocytopenia or another significant bleeding disorder.

Answer 10

Correct Answers:

Dimpling observed in one breast.

Rationale :

🪞Dimpling of the breast skin is an abnormal finding that can indicate underlying tissue retraction.

🧲Contracting the pectoral muscles by pressing the hands into the hips makes subtle skin retraction easier to observe.

🎗️Changes such as dimpling, puckering, or fixation should receive further clinical evaluation.

🔎Therefore, visible dimpling during this maneuver is the concerning finding.

📌Core Message

Breast dimpling or retraction is abnormal and warrants further assessment.

Laboratory Test	Reference Range	4/14	4/15	4/16	4/17
Red blood cells (RBC)	4.2–5.9 × 10¹²/L	5.1	4.8	4.9	5.2
Hemoglobin (Hgb)	12–17 g/dL	13	14	15	—
Hematocrit (Hct)	35%–57%	35	38	38	36
White blood cells (WBC)	4,000–10,000/mm³	9,400	9,000	8,430	8,800

Medication	4/14	4/15	4/16
Nicotine patch 21 mg transdermal daily	Given 09:03	Given 09:28	Given 09:38
Heparin 6,000 units subcutaneous BID	Given 00:03	Given 21:20	Given 00:28; Given 21:02
Ketorolac 30 mg IV three times daily PRN for pain	Given 11:00; Given 23:00	Given 10:00; Given 18:00	Given 14:00

NR304 CJE Health Assessment Open Check 2641

No.

1 :
The nurse percusses the lungs of a client with no lung problems. What is the expected assessment finding?

2 :
When admitting a 70-year-old client with dementia, the client states, "What time is my daughter coming home? I am hungry." Which nursing documentation about the client's neurological status is correct?

3 :
The nurse assesses a client and finds the right great toenail to be thick, and discoloured yellow and black. All other toenails appear normal on that same foot What education does the nurse anticipate providing to the client after the health care provider (HCP) sees the client?

4 :
The nurse palpates the client's dorsalis pedis and posterior tibial in the right lower extremity and determines that they cannot be felt. What is the priority nursing action?

5 :
The school nurse assesses the hair of students as there has been an outbreak of head lice in the school. What finding in one student indicates the student has head lice?

6 :
The nurse is caring for a client who had an embolic stroke and assesses for PERRLA. Which instruction should the nurse give the client to assess accommodation?

7 :
A nurse is caring for a patient.

Answer Options

8 :
The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 ML saline. At what rate will the nurse program the pump?

9 :
When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client's mouth and all over the abdomen, what is the priority nursing action?

10 :
In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?

NR304 CJE Health Assessment Open Check 2641

No.

1 : The nurse percusses the lungs of a client with no lung problems. What is the expected assessment finding?

2 : When admitting a 70-year-old client with dementia, the client states, "What time is my daughter coming home? I am hungry." Which nursing documentation about the client's neurological status is correct?

3 : The nurse assesses a client and finds the right great toenail to be thick, and discoloured yellow and black. All other toenails appear normal on that same foot What education does the nurse anticipate providing to the client after the health care provider (HCP) sees the client?

4 : The nurse palpates the client's dorsalis pedis and posterior tibial in the right lower extremity and determines that they cannot be felt. What is the priority nursing action?

5 : The school nurse assesses the hair of students as there has been an outbreak of head lice in the school. What finding in one student indicates the student has head lice?

6 : The nurse is caring for a client who had an embolic stroke and assesses for PERRLA. Which instruction should the nurse give the client to assess accommodation?

7 : A nurse is caring for a patient.

Answer Options

8 : The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 ML saline. At what rate will the nurse program the pump?

9 : When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client's mouth and all over the abdomen, what is the priority nursing action?

10 : In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?

1 :
The nurse percusses the lungs of a client with no lung problems. What is the expected assessment finding?

2 :
When admitting a 70-year-old client with dementia, the client states, "What time is my daughter coming home? I am hungry." Which nursing documentation about the client's neurological status is correct?

3 :
The nurse assesses a client and finds the right great toenail to be thick, and discoloured yellow and black. All other toenails appear normal on that same foot What education does the nurse anticipate providing to the client after the health care provider (HCP) sees the client?

4 :
The nurse palpates the client's dorsalis pedis and posterior tibial in the right lower extremity and determines that they cannot be felt. What is the priority nursing action?

5 :
The school nurse assesses the hair of students as there has been an outbreak of head lice in the school. What finding in one student indicates the student has head lice?

6 :
The nurse is caring for a client who had an embolic stroke and assesses for PERRLA. Which instruction should the nurse give the client to assess accommodation?

7 :
A nurse is caring for a patient.

8 :
The nurse receives an order to administer ceftriaxone 1.5 gram IV over 30 minutes to a client diagnosed with pneumonia. Available is ceftriaxone 2 grams/50 ML saline. At what rate will the nurse program the pump?

9 :
When the nurse performs a skin assessment on a young client newly admitted to the unit and finds petechiae in the client's mouth and all over the abdomen, what is the priority nursing action?

10 :
In teaching the female client how to perform breast self-examination, the nurse tells the client to stand before the mirror, put the hands on the hips, and push the palms into the hips. What is an abnormal finding with this aspect of the test?