The nurse is assessing the client's intake and output values for the shift (see chart below).

Intake for the shift

250mL Water

120mL Coffee

500mL Intravenous fluid

135 mL Orange Juice

120 mL Ice Cream

120 mL Jello

Output for the shift

545mL Urine

53mL Wound Drainage

200mL Emesis

375mL Urine

200mL Urine

75mL Loose Stool

480mL Urine

Based on these intake and output findings, what is the priority assessment by the nurse?

Palpate for pitting edema.

Assess for oral temperature.

Inspect the oral mucosa.

Auscultate adventitious lung sounds.

Answer and Explanation

The Correct Answer is C

A. Palpating for pitting edema assesses for fluid overload, but this client is more likely experiencing fluid deficit rather than retention.
B. Assessing oral temperature is important, but there is no indication of infection or fever contributing to fluid loss in this scenario.
C. Inspecting the oral mucosa is correct because the client's total intake (1,245 mL) is significantly lower than their total output (1,928 mL), indicating a negative fluid balance. Signs of dehydration, such as dry oral mucosa, should be assessed first.
D. Auscultating adventitious lung sounds is relevant for fluid overload but is not the priority in a case of fluid deficit.

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Correct Answer is D

Explanation

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

A. Clubbing of the fingers B. Bilateral crepitus C. Bilateral peripheral edema D. Increased anteroposterior diameter

Correct Answer is C

Explanation

A. Clubbing of the fingers is a chronic finding associated with long-term hypoxia from respiratory diseases such as chronic lung disease or cystic fibrosis, not acute heart failure.
B. Bilateral crepitus suggests air trapping or alveolar collapse, which is more indicative of pneumonia or emphysema, rather than a primary cardiac cause.
C. Bilateral peripheral edema is correct. Dyspnea that worsens when lying flat (orthopnea) and the need for multiple pillows to sleep comfortably are signs of heart failure. Peripheral edema indicates fluid overload due to poor cardiac function.
D. Increased anteroposterior diameter is associated with chronic respiratory conditions like COPD, where lung hyperinflation leads to a "barrel chest" appearance. This is not a typical finding in heart failure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

Correct Answer is C

Explanation

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?