(inspect, auscultate, percuss palpate)
Auscultate for 2 min to determine if bowel sounds are absent (at
least 5 minutes)
Place the diaphragm of the
over each quadrant
Ask the client to cough upon auscultation (for lung assessment)
A nurse is delegating client care to an assistive personnel. Which of
the following tasks should the nurse delegate?
Evaluating healing of an incision- nursing process is RNs job
Inserting a NG Tube- LVN can do this
Performing a simple dressing
key word is SIMPLE so this
should be it .
D. Changing IV tubing.- LVN or RN can do t his
A nurse is screening several clients at a neighborhood health fair.
Which of the following assessment findings is the priority for
referral for further care?
BMI 25 kg/m2
Glucose 45mg/dl- can lead to coma and seizure and death if not
57. A nurse is assessing a client’s extraocular eye movements. Which
of the following actions should the nurse take?
Position the client 6.1m(20ft) away from the Snellen chart.
Instruct the client to follow finger through the
Ask the client to cover her right eye during assessment of her left
Hold a finger 46cm (18inch) in front of the client’s eye.
58.A nurse is planning care for a client who has prescription of knee-
length antibolic stockings. Which of the following actions should the
nurse take? P . 224 ati funds
Remove the client’s stockings at least once each
book says every 8 hours
you remove and asses for
redness warmth and
Roll the top of the client’s stocking down to just below the knee.-
you pull up the leg
Seat the client in a chair for 30min prior to applying stockings