NCLEX/ATI/Text Questions - NSG 200 - Respiratory/Cardiovascular Assessment

A nurse is assessing the hematologic system of an older adult client. The nurse should report which of the following findings to the provider as a possible indication of a hematologic disorder? A. Pallor B. Jaundice C. Absence of hair on the legs D. Poor nailbed capillary refill

C. Absence of hair on the legs A progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider

A nurse is caring for a client who reports calf pain. What is the first action the nurse should take? A. Notify the provider B. Elevate the affected extremity C. Check the affected extremity for warmth and redness D. Prepare to administer unfractionated heparin

C. Check the affected extremity for warmth and redness The first action the nurse should take using the nursing process is to assess the client's calf for swelling, redness, and warmth. These findings can indicate a deep vein thrombophlebitis.

What age-related cardiovascular changes should the nurse assess for when providing care to an older adult patient? (Select all that apply.) 1. Systolic murmur 2. Diminished pedal pulses 3. Increased maximal heart rate 4. Decreased maximal heart rate 5. Increased recovery time from activity

1. Systolic murmur 2. Diminished pedal pulses 4. Decreased maximal heart rate 5. Increased recovery time from activity

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over which area? 1. The major bronchi 2. The trachea and larynx 3. The peripheral lung fields 4. The lower posterior thorax

1. The major bronchi Rationale: Bronchovesicular breath sounds are heard over major bronchi. The upper sternum area is where major bronchi are located. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Vesicular breath sounds are heard over the peripheral lung fields.

A patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? 1. "Bibasilar wheezes present on inspiration." 2. "Diminished breath sounds in the bases of both lungs." 3. "Fine crackles posterior right and left lower lung fields." 4. "Expiratory wheezing scattered throughout the lung fields."

3. "Fine crackles posterior right and left lower lung fields."

Which patient has early clinical manifestations of hypoxemia? 1. A 48-yr-old patient who is intoxicated and acutely disoriented to time and place. 2. A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair. 3. A 72-yr-old patient who has four new premature ventricular contractions per minute. 4. A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output.

3. A 72-yr-old patient who has four new premature ventricular contractions per minute. Rationale: Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. A blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3. A blowing or swooshing noise Rationale: A heart murmur is an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

The nurse would perform which action to assess for a pulse deficit? 1. Count the carotid pulsations for 1 full minute. 2. Measure the blood pressure in both the arm and leg. 3. Auscultate the apical heartbeat while palpating the radial artery. 4. Place the diaphragm of the stethoscope directly over the skin at the mitral area.

3. Auscultate the apical heartbeat while palpating the radial artery. Rationale: A pulse deficit is the difference between the apical and peripheral pulses and could indicate a dysrhythmia. If an irregularity in the pulse is noted, the nurse would check for a pulse deficit. To check for a pulse deficit the nurse would auscultate the apical heart rate and rhythm while palpating a peripheral artery and assess for a difference in the rates. A difference in the rates indicates a pulse deficit.

When auscultating the patient's lower lungs, the nurse hears low-pitched sounds similar to blowing through a straw under water on inspiration. How should the nurse document these sounds? 1. Stridor 2. Vesicular 3. Coarse crackles 4. Bronchovesicular

3. Coarse crackles

Which aspect of the heart's action does the QRS complex on the ECG represent? 1. Depolarization of the atria 2. Repolarization of the ventricles 3. Depolarization from atrioventricular (AV) node throughout ventricles 4. The length of time it takes for the impulse to travel from the atria to the ventricles

3. Depolarization from atrioventricular (AV) node throughout ventricles The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.

Which action should the nurse implement with auscultation during a patient's cardiovascular assessment? 1. Position the patient supine. 2. Ask the patient to hold their breath. 3. Palpate the radial pulse while auscultating the apical pulse. 4. Use the bell of the stethoscope when auscultating S1 and S2.

3. Palpate the radial pulse while auscultating the apical pulse.

A nursing student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? 1. Palpating over the lung apices in the supraclavicular area 2. Asking the client to repeat the word ninety-nine during palpation 3. Palpating over the breast tissue to assess and compare vibrations from one side to the other 4. Comparing vibrations from one side to the other as the client repeats the word ninety-nine

3. Palpating over the breast tissue to assess and compare vibrations from one side to the other Rationale: When assessing for tactile fremitus, the nurse would begin palpating over the lung apices in the supraclavicular area. The nurse would compare vibrations from one side to the other as the client repeats the word ninety-nine.

Which part of the electrical conduction system of the heart is considered the "pacemaker" of the heart? 1. Bundle of His 2. Purkinje Fibers 3. Sinoatrial Node 4. Atrioventricular Node

3. Sinoatrial Node (SA)

The nurse is palpating the patient's chest during a focused respiratory assessment in the emergency department. Which finding is a medical emergency? 1. Increased tactile fremitus 2. Diminished chest movement 3. Tracheal deviation to the left 4. Decreased anteroposterior (AP) diameter

3. Tracheal deviation to the left

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4.Diminished

3. Wheezes Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6° F (37° C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question would the nurse ask the client first? 1. "Do you exercise regularly?" 2. "Are you considering trying to lose weight?" 3. "Is there a history of diabetes mellitus in your family?" 4. "When was the last time you had your blood pressure checked?"

4. "When was the last time you had your blood pressure checked?"

The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding? 1. Stenosis of the heart valves 2. Decreased adrenergic sensitivity 3. Increased parasympathetic activity 4. Loss of elasticity in arterial vessels

4. Loss of elasticity in arterial vessels

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1. Over the second intercostal space at the left sternal border 2. Over the fourth intercostal space at the right sternal border 3. Over the second intercostal space at the right sternal border 4. Over the fifth intercostal space in the left midclavicular line

4. Over the fifth intercostal space in the left midclavicular line

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? 1. Wheezes 2. Rhonchi 3. Crackles 4. Pleural friction rub

4. Pleural friction rub Rationale: A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.

Which anatomic feature of the heart directly stimulates ventricular contractions? 1. SA node 2. AV node 3. Bundle of His 4. Purkinje fibers

4. Purkinje fibers The Purkinje fibers move the electrical impulse or action potential through the walls of both ventricles triggering synchronized right and left ventricular contraction. The sinoatrial (SA) node initiates the electrical impulse that results in atrial contraction. The atrioventricular (AV) node receives the electrical impulse through internodal pathways. The bundle of His receives the impulse from the AV node.

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What would the nurse include in the client's focused assessment? 1. Ability to drive a car 2. The normal everyday routine in the home 3. Ability to do light or heavy housework and to pay bills 4. Self-care needs such as toileting, feeding, and ambulating

4. Self-care needs such as toileting, feeding, and ambulating

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. Necrosis B. Hypokalemia C. Hypomagnesemia D. Insufficiency

A. Necrosis ST-segment elevation during an acute myocardial infarction indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate revascularization of the artery.

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor The nurse should identify that stridor (a high-pitched crowing sound heard during inspiration) is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call the rapid response team for assistance before the airway becomes completely obstructed.

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

A. Use pursed-lip breathing during periods of dyspnea

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1 kg (2.2 lb) in 1 day B. Pitting edema +1 C. Client report of a nocturnal cough D. B-type natriuretic peptide (BNP) level of 100 pg/mL

A. Weight gain of 1 kg (2.2 lb) in 1 day A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Pitting peripheral edema B. Crackles in the lung bases C. Jugular vein distention D. Hepatomegaly

B. Crackles in the lung bases

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

B. Dysrhythmias According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.

A nurse completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.) A. Hypothyroidism B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

B. Hypertension C. Diabetes mellitus D. Hyperlipidemia E. Tobacco smoking

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect? A. Flattened T waves B. Prolonged QT intervals C. Shortened QT intervals D. Widened QRS complexes

B. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen.

C. "Platelets plug breaks in blood vessels."

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."

C. "When I breathe out through pursed lips, my airways don't collapse between breaths."

Which subjective data related to the cardiovascular system should be obtained from the patient (select all that apply)? a. Annual income b. Smoking history c. Religious preference d. Number of pillows used to sleep e. Blood for basic laboratory studies

b. Smoking history c. Religious preference d. Number of pillows used to sleep

When assessing a patient, you note a pulse deficit of 23 beats. This finding may be caused by a. dysrhythmias. b. heart murmurs. c. gallop rhythms. d. pericardial friction rubs.

a. dysrhythmias.

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective? 1. "This is mostly used in a walk-in clinic or emergency department." 2. "This is focused on disease detection and conducted in a health care provider's office." 3. "This is conducted on admission in a primary care or long-term care setting." 4. "This is conducted as a follow-up examination by a health care provider."

1. "This is mostly used in a walk-in clinic or emergency department." Rationale: A problem-based assessment involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department. A screening assessment is a limited examination focused on disease detection. A complete assessment includes a complete health history and physical examination and forms a baseline database. It is performed on admission to a primary care or long-term care setting. An episodic or follow-up assessment is done when a client is being followed up for a previously identified or treated problem.

The nurse determines that a patient's pedal pulses are absent. What factor could contribute to this finding? 1. Atherosclerosis 2. Hyperthyroidism 3. Atrial dysrhythmias 4. Arteriovenous fistula

1. Atherosclerosis

The nurse is performing a focused respiratory assessment of a patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? 1. Auscultation of bilateral breath sounds 2. Percussion of anterior and posterior chest wall 3. Palpation of the chest bilaterally for tactile fremitus 4. Inspection for anterior and posterior chest expansion

1. Auscultation of bilateral breath sounds

A frail older adult patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? 1. Bases of the posterior chest area 2. Apices of the posterior lung fields 3. Anterior chest area above the breasts 4. Midaxillary on the left side of the chest

1. Bases of the posterior chest area Rationale: Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

The nurse is providing care for a patient who has decreased cardiac output due to heart failure. As a basis for planning care, what should the nurse understand about cardiac output (CO)? 1. CO is calculated by multiplying the patient's stroke volume by the heart rate. 2. CO is the average amount of blood ejected during one complete cardiac cycle. 3. CO is determined by measuring the electrical activity of the heart and the heart rate. 4. CO is the patient's average resting heart rate multiplied by the mean arterial blood pressure.

1. CO is calculated by multiplying the patient's stroke volume by the heart rate.

During the respiratory assessment, the nurse auscultates low-pitched sounds that sound like ripping of Velcro and will document what findings that describe the sounds? 1. Coarse Crackles 2. Fine Crackles 3. Sonorous Wheezes 4. Pleural Friction Rub

1. Coarse Crackles

When assessing the patient in acute respiratory distress, what should the nurse expect to observe? (Select all that apply.) 1. Cyanosis 2. Tripod Position 3. Kussmaul Respirations 4. Accessory muscle use 5. Increased AP diameter

1. Cyanosis 4. Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient? (Select all that apply.) 1. Is it hard for you to fall asleep? 2. Do you awaken abruptly during the night? 3. Do you sleep more than 8 hours per night? 4. Do you need to sleep with the head elevated? 5. Do you often need to urinate during the night?

1. Is it hard for you to fall asleep? 2. Do you awaken abruptly during the night? 4. Do you need to sleep with the head elevated?

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 1. Mitral area 2. Right atrium 3. Right ventricle 4. Pulmonic valve

1. Mitral area Rationale: The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) would be distinguished. The pulse would be counted for a full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear auscultation of the apical pulse.

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What other manifestations should the nurse expect to observe in this patient? 1. Restlessness, tachypnea, tachycardia, and diaphoresis 2. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis 3. Combativeness, retractions with breathing, cyanosis, and decreased output 4. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

1. Restlessness, tachypnea, tachycardia, and diaphoresis

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1. Rhythmic respirations with periods of apnea Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? 1. Frequency, family history, hematemesis 2. Cough sound, sputum production, pattern 3. Weight loss, activity tolerance, orthopnea 4. Smoking status, medications, residence location

2. Cough sound, sputum production, pattern

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the primary health care provider. 4. Reassess the respiratory rate in 15 minutes.

2. Document the findings. Rationale: The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical heart rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location? 1. Near the lateral 12th rib 2. Just under the left clavicle 3. In the fifth intercostal space 4. Posteriorly under the left scapula

2. Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. The nurse would place the stethoscope just under the left clavicle. The other options are incorrect locations.

While auscultating the patient's heart sounds with the bell of the stethoscope, the nurse hears a ventricular gallop. How should the nurse document what is heard? 1. Diastolic murmur 2. Third heart sound (S3) 3. Fourth heart sound (S4) 4. Normal heart sounds (S1, S2)

2. Third heart sound (S3) The third heart sound is heard closely after the S2 and is known as a ventricular gallop because it is a vibration of the ventricular walls associated with decreased compliance of the ventricles during filling. It occurs with left ventricular failure. Murmurs sound like turbulence between normal heart sounds and are caused by abnormal blood flow through diseased valves. The S4 heart sound is a vibration caused by atrial contraction, precedes the S1, and is known as an atrial gallop. The normal S1 and S2 are heard when the valves close normally.

The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation reveals a heart murmur. What does this assessment finding indicate? 1. Increased viscosity of the patient's blood 2. Turbulent blood flow across a heart valve 3. Friction between the heart and the myocardium 4. A deficit in conductivity impairs normal contractility

2. Turbulent blood flow across a heart valve

A nurse is preparing to teach a group of women in a community volunteer group about heart disease. What should the nurse include in the teaching plan? 1. Women are less likely to delay seeking treatment than men. 2. Women are more likely to have noncardiac symptoms of heart disease. 3. Women are often less ill when presenting for treatment of heart disease. 4. Women have more symptoms of heart disease at a younger age than men.

2. Women are more likely to have noncardiac symptoms of heart disease.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: 1. pain. 2. atelectasis. 3. pneumonia. 4. pleural effusion.

2. atelectasis. After surgery, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Jugular vein distension B. Moist crackles C. Postural hypotension D. Increased heart rate E. Fever

A. Jugular vein distension B. Moist crackles D. Increased heart rate The increased venous pressure due to excessive circulating blood volume results in neck vein distension. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses.

A nurse is providing teaching for a client who has a prescription for a lowsodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

A. "I can snack on fresh fruit."

A nurse is caring for a client who is undergoing treatment for hypertension. Which of the following statements indicates that the client is adhering to the treatment plan? A. "I would never have believed I could get used to enjoying my food without salt." B. "My blood pressure device at home usually shows about 156 over 98 or so." C. "I make sure I take my blood pressure medicine when I have headaches." D. "My blood pressure pills are very expensive. Could I take a cheaper medication?"

A. "I would never have believed I could get used to enjoying my food without salt."

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motorvehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub

A. Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.

A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hyperkalemia The nurse should monitor the client for hyperkalemia because chronic respiratory acidosis can result in high potassium levels due to potassium shifting out of the cells into the extracellular fluid.

A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? A. Increased hematocrit level B. Bradycardia C. Distended neck veins D. Decreased urine specific gravity

A. Increased hematocrit level The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax

A nurse in a clinic is assessing the lower extremities and ankles of a client who has a history of peripheral arterial disease. Which of the following findings should the nurse expect? A. Pitting edema B. Areas of reddish-brown pigmentation C. Dry, pale skin with minimal body hair D. Sunburned appearance with desquamation

C. Dry, pale skin with minimal body hair A client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin with minimal body hair because of narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities, which can lead to tissue damage. Common manifestations are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep-breathing and coughing D. Assist the client with ambulation

C. Encourage deep-breathing and coughing

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? A. Headache B. Hemoptysis C. Nausea D. Diarrhea

C. Nausea Nausea is an associated manifestation of MI. Manifestations of MI include chest pain and pain in the jaw, shoulder, or abdomen.

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

D. Place the client in an upright position

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Decreased capillary refill B. Dyspnea C. Orthopnea D. Dependent edema

D. Dependent edema Blood return from the venous system to the right atrium is impaired by a weakened right heart. The subsequent systemic venous backup leads to the development of dependent edema.

A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? A. Insufficient skin care B. Dehydration C. Immobility D. Impaired circulation

D. Impaired circulation

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

D. Noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.

A nurse is reviewing the progress notes for a client who has heart failure. The provider noted some improvement in the client's cardiac output. The nurse should understand that cardiac output reflects which of the following physiologic parameters? A. The percentage of blood the ventricles pump during each beat B. The amount of blood the left ventricle pumps during each beat C. The amount of blood in the left ventricle at the end of diastole D. The heart rate times the stroke volume

D. The heart rate times the stroke volume Cardiac output is the product of the client's heart rate and stroke volume (the amount of blood the left ventricle pumps with each contraction). In systolic heart failure, the heart cannot pump enough oxygenated blood into the circulation, causing cardiac output to decrease.

A nurse is caring for a client who has pernicious anemia. Which of the following factors should the nurse identify with this condition? A. Iron deficiency B. Hemolytic blood loss C. Folic acid deficiency D. Vitamin B12 deficiency

D. Vitamin B12 deficiency A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.

A patient has a severe blockage in his right coronary artery. Which heart structures are most likely to be affected by this blockage (select all that apply)? a. AV node b. Left ventricle c. Coronary sinus d. Right ventricle e. Pulmonic valve

a. AV node b. Left ventricle d. Right ventricle

Which nursing responsibilities are priorities when caring for a patient returning from a cardiac catheterization (select all that apply)? a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses c. Helping the patient to ambulate to the bathroom to void d. Telling the patient that he will be sleepy from the general anesthesia e. Teaching the patient about the risks of the radioactive isotope injection

a. Monitoring vital signs and ECG b. Checking the catheter insertion site and distal pulses

Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the (select all that apply) a. cough reflex. b. mucociliary escalator. c. alveolar macrophages. d. reflex bronchoconstriction. e. alveolar capillary membrane.

a. cough reflex. b. mucociliary escalator. c. alveolar macrophages. d. reflex bronchoconstriction.

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

a. Thoracentesis

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3-). e. compliance and resistance.

a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3-).

The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the a. carina. b. larynx. c. trachea. d. epiglottis.

a. carina.

Which heart valve sound is heard best at the left midclavicular line at the level of the fifth ICS? a. Aortic b. Mitral c. Tricuspid d. Pulmonic

b. Mitral

A P wave on an ECG represents an impulse arising at the a. SA node and repolarizing the atria. b. SA node and depolarizing the atria. c. AV node and depolarizing the atria. d. AV node and spreading to the bundle of His.

b. SA node and depolarizing the atria.

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.

b. apprehension and restlessness.

When auscultating the chest of an older patient in mild respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.

b. begin listening at the lung bases.

When a person's blood pressure rises, the homeostatic mechanism to compensate for an elevation involves stimulation of a. baroreceptors that inhibit the sympathetic nervous system, causing vasodilation. b. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation. c. baroreceptors that inhibit the parasympathetic nervous system, causing vasodilation. d. chemoreceptors that stimulate the sympathetic nervous system, causing an increased heart rate.

b. chemoreceptors that inhibit the sympathetic nervous system, causing vasodilation.

When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse asks about (select all that apply) a. date of last chest x-ray. b. dyspnea during rest or exercise. c. pulmonary function test results. d. ability to sleep through the entire night. e. prescription and over-the-counter medication.

b. dyspnea during rest or exercise. d. ability to sleep through the entire night. e. prescription and over-the-counter medication.

The part of the vascular system responsible for hemostasis is the a. thin capillary vessels. b. endothelial layer of the arteries. c. elastic middle layer of the veins. d. smooth muscle of the arterial wall.

b. endothelial layer of the arteries.

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

c. arterial oxygen partial pressure.

An expected finding in the assessment of an 81-year-old patient is a. a narrowed pulse pressure. b. diminished carotid artery pulses. c. difficulty isolating the apical pulse. d. an increased heart rate in response to stress.

c. difficulty isolating the apical pulse.

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. decreased lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

c. increased residual volume. d. decreased lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

A patient with a tricuspid valve disorder has impaired blood flow between the a. vena cava and right atrium. b. left atrium and left ventricle. c. right atrium and right ventricle. d. right ventricle and pulmonary artery.

c. right atrium and right ventricle.

Which respiratory assessment finding does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields

d. Bronchial breath sounds in the lower lung fields

A patient asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. positive intrathoracic pressure. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.

d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.