1. A nurse is conducting an admission interview with a client. Which of the following pieces of

assessment information should the nurse collect during the introductory phase of the

interview?

A. Clients level of comfort and ability to participate in the interview

-The nurse should assess the client’s level of comfort and establish a rapport during the

introductory or orientation phase. The nurse should engage in active listening and present a

relaxed attitude to place the client at ease and encourage client participation. This will assist the

nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

B. Previous illnesses and surgeries

-incorrect: The nurse should assess the client’s health history, including previous illnesses and

surgeries, during the working phase of the interview.

C. Events surrounding the client’s recent illness

-incorrect: The nurse should assess the client’s health history, including events surrounding the

recent or current illness, during the working phase of the interview.

D. Sociocultural history

-incorrect: The nurse should assess the client’s sociocultural history during the working phase of

the interview.

2. A nurse is performing an abdominal assessment of a client. Which of the following positions

should the nurse tell the client to assume for this examination?

A. Lithotomy

-incorrect: The lithotomy position is useful for gynecological examinations.

B. Lateral

-incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This

position is useful when auscultating the heart to detect murmurs.

C. Supine

-The nurse should tell the client to assume the supine position to promote relaxation of the

abdominal muscles. Having the client bend the knees enhances relaxation of the stomach

muscles.

D. Sims

-incorrect: The Sims’ position limits access to the abdomen. This position is useful for rectal and

vaginal examinations.

3. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of

the following actions should the nurse perform first after discovering the client’s wound has

eviscerated?

A. Cover the incision with a moist sterile dressing

- The nurse should apply the safety and risk-reduction priority-setting framework, which assigns

priority to the factor or situation posing the greatest safety risk to the client. When there are

several risks to client safety, the one posing the greatest threat is the highest priority. The nurse

should use Maslow’s Hierarchy of Needs, the ABC priority-setting framework, and/or nursing

knowledge to identify which risk poses the greatest threat to the client. An open wound