Summer Lab

Where is the tympanic thermometer used?

The ear

The nurse is taking vital signs on a newly admitted client. Which
interventions should the nurse implement?

Count respirations for 30 seconds and multiply by 2.
Palpitate the clients brachial pulse prior to
taking the blood pressure.
Take the radial pulse for 15
seconds and multiply by four.

Nurse is ambulating a client with a weak left side down the hall.
Which action should nurse implement?
a vest restraint
closed toe shoes on client
another nurse to help
stand in front of client when ambulating

closed toed shoes

When should a fracture bed pan be used?

For clients with back pain, back or hip surgery.

An elderly client on bed rest is requesting a bed pan. What action
should the nurse implement?
bedside commode
regular bedpan
fracture bedpan
encourage client to ambulate to the bathroom

regular bed pan

What is normal systolic blood pressure

100- 140 mm Hg

What is normal diastolic blood pressure

60-90 mm Hg

The nurse is ambulating a client down the hall. Which is most important?
Clients elbow to remain straight
The straight cane provides the most support
The clients elbow should be slightly flexed
The quad cane provides the least support

The clients elbow should be slightly flexed

The nurse is fitting the client for crutches. Which
pathological complication may occur if the crutches
are not the correct length?
axillary nerve damage
the client could fall
brachial plexus paralysis
shoulder dislocation

Axillary nerve damage

The client had right leg surgery two days ago and the nurse aid is
applying a heating pad to the surgical area. Which intervention should
the nurse implement first?
notify health care provider heat was applied to the surgical site
instruct the nurse aide to remove the heating pad from the right leg
explain to the nurse aide that cold therapy should be applied to the leg
assist the nurse aide in applying the heating pad

instruct the nurse aide to remove the heating pad from the right leg

The nurse can delegate obtaining weight and height, bathing, and
vital signs of a stable patient.

...

The nurse cannot delegate teaching, evaluating, medications or
anything to an unstable client. The nurse cannot delegate anything
that should be done by an individual in another department, such as housekeeping.

...

Kneading strokes that would stimulate circulation

Petrissage

Long smooth strokes that are relaxing

Effleurage

Rhythmic percussion

Tapotement

Small circular strokes

Friction

A 55 year old clients radial pulse is 110 beats a minute. Which
action should the student nurse implement first?
Take no action since the pulse is within normal limits
Assess the client to determine the reason why pulse is elevated.
Notify the charge nurse that the pulse is elevated.
Attempt to calm the client and take the pulse again in one hour.

Assess the client to determine the reason why pulse is elevated.
normal pulse rate is 60-100 bpm

What is a normal pulse rate?

60-100 bpm

The nurse is repositioning a client in low fowler's position. Which
action should the nurse implement?
Evaluate head of bed to 90 degrees
Bend the clients knees slightly
Position the client's trunk at a slight right angle to the bed
Place the client in the prone position

Bend the client's knees slightly.
The clients head should be elevated to about 30 degrees.

Knees slightly bent. Head elevated to about 30 degrees.

Low Fowler's position

Position on the stomach.

Prone position

90 Degrees

Client sitting straight up in the bed.

The client is complaining of severe abdominal pain. The nurse needs
to assess the clients respirations. Which action should the nurse
implement first?
Report any abnormal findings to the charge nurse
Count the respirations for 30 seconds and multiply by 2
Hold the clients wrist after assessing the radial pulse and assess
the clients respirations
Wait for at least 15 minutes prior to assessing the clients respirations

Wait for at least 15 minutes prior to assessing the clients respirations
Anxiety, discomfort, or exercise will increase the respiratory rate
and result in a false reading. The other options are all correct but
the nurse should wait until the client is not upset.

The nurse is assessing a client prior to transfer. Which assessment
data is most important when transferring client from bed to chair?
Can the client bear weight?
How much does the client weigh?
Can the client bear weight?
Does the client cooperate and follow instructions?

Can the client provide assistance
The most important question is to determine if the nurse will need
assistance to transfer the client. This ensures nurse and client safety.

Helps decrease a fever.

Cool water bath

Used to soften and lubricate dry skin

Oatmeal or Aveeno bath

Can be used to relieve muscle spasms and tension

Warm water bath

Used to help decrease pain and inflammation after rectal surgery

Sitz bath

The nurse walks in to the client's room and notices that the urinal
at the bedside has clear colored amber urine. Which action should the
nurse implement first?
Document in the I & O sheet
Rinse the urinal with water
Measure the amount of urine
Empty the urine in the clients commode

Measure the amount of urine.
The nurse must first measure the urine, then empty the urinal, rinse
the urinal and then document the amount on the Intake and Output sheet.

The nurse is observing the client ambulating with a walker. Which
action by the client should warrant intervention by the nurse?
The client takes small steps while moving the walker forward.
The client has on comfortable, supportive shoes while walking.
The client is lifting the walker and moving it about one step length forward.
The client has both hands on the sides of the walker.

The client takes small steps while moving the walker forward.
The client should not take small steps while moving the walker
forward. The client should move the walker about one step forward then
plant the walker and then take small steps.

The nurse is performing passive range of motion to the patients knee.
Which exercise should be included?
Abduction
Circumduction
Eversion
Flexion
Extension

flexion and extension

the action of bending or the condition of being bent, especially the
bending of a limb or joint.

flexion

the stretching of a fractured or dislocated limb so as to restore it
to its natural position. 2 : an unbending movement around a joint in a
limb (as the knee or elbow) that increases the angle between the bones
of the limb at the joint � compare flexion sense

Extension

the movement of a limb or other part toward the
midline of the body or toward another part.

adduction

movement of a limb or other part away from the
midline of the body, or from another part.

abduction - to take away

movement of a limb or extremity so that the distal end describes a
circle while the proximal end remains fixed.

Circumduction