NSG200 Final Exam

What is an expected finding on palpation of the chest wall?

I think tapping felt on the chest wall at the left fifth intercostal space with the patient turned on the left lateral position

To begin assessing a patient's left upper lobe of the lung anteriorly, the nurse places the styhoscope

Above the clavicle

A nurse is interested in providing community education in screening on risks for heart disease and stroke. In order to reach a priority population, to which target audience to the nurse provide this service

African-American churches

A patient has been diagnosed with chronic venous stasis. Which of the following clinical manifestations would the nurse expect to observe? A. Thin, shiny, atrophic skin B. A brownish discoloration to the skin of the lower leg C. A unilateral cool foot D. Pallor of the toes and decreased capillary refill

B. A brownish discoloration to the skin of the lower leg

A seventy-five year old female is being evaluated for shortness of breath. Which of the following questions would best assess the degree of dyspnea? A. How long have felt short of breath? B. Did anything happen which caused you to become short of breath? C. How far can you walk without becoming short of breath? D. Do you have a cough?

C. How far can you walk without becoming short of breath?

Which of the following characteristics differentiate crackles from wheezes?

Crackles are discontinuous, popping sounds, and wheezes are continuous, musical sounds

The manubrium sternal angle is also called the angle of Louis. What is the significance of this landmark when performing an assessment of the lungs and thorax?

The right and left mainstem bronchi branch off the trachea at the angle of Louis

The nurse is assessing a client apical impulse. Which would be an expected finding?

The size of the impulse is approximately 1 x 2 cm

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

aortic and pulmonic

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most Likely results from

increased density of lung tissue

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:

vesicular breath sounds and are normal in that location.

When assessing a patient, the nurse documents the left femoral pulse as 0/0-3+. Which of the following findings would be expected at the dorsalis pedis pulse?

0/0-3+

The nurse is assessing a 72 year old client diagnosed with aortic valvular stenosis. The murmur from this valvular defect can be assessed by auscultating at the

2nd right ICS at the sternal border

During the precordial assessment of a woman who is eight months pregnant, the nurse palpate the apical impulse at the fourth left intercostal space lateral to the midclavicular line. What does the findings indicate?

Displacement of the heart from enlargement of the uterus

The nurse is performing in neurovascular assessment on a client diagnosed with peripheral arterial disease. Which assessment findings support this diagnosis?

Feet and legs are pale in color when elevated The client reports tingling and numbness in both feet The client reports like pain with walking that is relieved by rest

A nurse is caring for a 2 month old infant diagnosed with ventricular septal defect. Which assessment data would be the most concerning to the nurse as an indicator of heart failure in this infant?

Heart rate persistently greater than 200bpm

Client reports coughing up blood he sputum. What time should the nurse use to document this finding?

Hemoptysis

The nurse is preparing to auscultate a clients carotid artery's. Which information should the nurse give the client?

Hold your breath

To document the palpation of a pulse, the nurse is correct and making which notation about the rhythm?

Irregular rhythm

A hospitalized client is scheduled to have an arterial blood gas drawn. Which assessment must be performed by the nurse prior to the ABG?

Modified Allen's test

A client tells the nurse that he/she is not able to lie down to sleep because of shortness of breath and sleeps in a recliner. Which term should the nurse use to document this problem?

Orthopnea

The nurse is assessing a client diagnosed with heart failure. Which clinical manifestations indicate the client Is experiencing impaired Perfusion? Select all that apply.

Pale, cool, moist skin Decreased urinary output Decreased level of alertness

Which of the following guidelines may be used to identify which heart sound is S1?

S1 coincides with the carotid artery pulse.

Which statement is true regarding the arterial system?

The arterial system is a high-pressure system

The nurse is assessing a client diagnosed with stenosis of the mitral valve. What position will the nurse ask the client to assume to facilitate auscultation of the murmur resulting from this valvular defect?

The lateral recumbent

The nursing student is reviewing anatomy and physiology of the best. Which statement by the student indicates correct understanding of cardiac anatomy and physiology?

The tricuspid and mitral valves are atrioventricular valves.

A nurse informed the patient that her blood pressure is 128/78. The patient asks what the number 128 meets. What is the nurses appropriate response? The 128 represents the pressure in your blood vessels when

The ventricles contract and the mitral and tricuspid valve close

When auscultating the lungs in an adult client, The nurse would

Use the diaphragm of the stethoscope held firmly against the chest

inability to palpate the spleen is...

normal

The nurse has noted unequal chest expansion and recognizes that this occurs when

part of the lung is obstructed or collapsed

On palpation of the left upper quadrant of the abdomen of a female patient, the nurse notes tenderness. This finding may indicate a disorder in which organ?

spleen

While taking a history, a nurse learns that this patient experiencing shortness of breath. If the cause of the dyspnea is it cardiovascular problems, the nurse expect which abnormal findings on examination?

Edema of the feet and ankles

A nurse notes enlargement of the left ventricle on the clients echocardiogram report. Which finding during inspection of the precordium correlates with this data?

Invisible lifting of the chest wall along the 4th to 5th left intercostal space at the midclavicular line

The healthcare provider has ordered an ankle brachial index ABI to be performed on a client admitted with leg pain. How should the nurse proceed?

Measure arm systolic blood pressure and ankle blood systolic pressure. Divide the ankle SBP by the arm SBP

Where should the nurse place his or her hands when performing an assessment of posterior thoracic expansion?

On the posterior lateral thorax with the thumbs at the level of T9 to T10

How does the nurse accurately palpate carotid pulses?

One finger is placed along the right and then the left medial sternocleidomastoid muscle

When inspecting the shape and configuration of the thoracic cage, which of the following would be an expected finding?

An anteroposterior diameter that is half of the transverse diameter

Adventitious sounds heard when auscultating the lungs are: A. Additional sounds not normally heard in the lungs B. Only heard with the bell of the stethoscope C. Best heard in the lower lobes of the lungs D. Augmented sounds related to an increased rate and depth of respirations

A. Additional sounds not normally heard in the lungs

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.

A. Atelactatic crackles that do not have a pathological cause

A four-year-old child is brought to the clinic for a preschool physical. Where would the nurse anticipate palpating the child apical impulse? A. Fourth left intercostal space lateral to the midclavicular line B. Fifth left intercostal space near the sternal border C. Fifth left intercostal space lateral to the midclavicular line D. Fourth left intercostal space near the sternal border

A. Fourth left intercostal space lateral to the midclavicular line

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?

An anteroposterior-to-transverse diameter ratio of 1:1

The clients x-ray report shows pneumonia in the right middle lung lobe. Where should the nurse place the stethoscope to auscultate for the adventitious breath sounds related to this fine day?

Anteriorly and laterally at right intercostal space 4-6

A nurse expects which finding when assessing the abdomen of a patient who has been unable to void for 12 hours?

Dull tones over the suprapubic area

The nurse is unable to palpate the popliteal pulse when performing a peripheral vascular assessment. Which action can the nurse Implement to facilitate palpation of the pulse?

Ask the client to assume the prone position and reassess

The nurse is planning to percuss The chest of an adult client for diaphragmatic excursion. The nurse should begin the assessment by

Asking the client to exhale and hold it

A 70 year old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets really dizzy and feels like she's going to fall over. What should be the nurses action?

Assess the clients blood pressure in a sitting and standing position

A nurse inspects the abdomen for skin color, surface characteristics, and contour. What part of the abdominal assessment does the nurse perform next?

Auscultation of the bowel sounds in all four quadrants?

A two-year-old is brought to the emergency room by his parent with a clearly audible harsh, high-pitched inspiratory sound. How should the nurse document the sound? A. Rhonchi B. Stridor C. Wheezing D. Crackles

B. Stridor

A 65-year-old male is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. How should the nurse document these symptoms? A. The client is experiencing pain due to deep vein thrombosis B. The client is experiencing exercise pain consistent with intermittent claudication C. The client is experiencing pain related to muscle disuse D. The client is experiencing pain due to varicose veins

B. The client is experiencing exercise pain consistent with intermittent claudication

Which instruction should the nurse give a patient to facilitate in palpating the femoral pulse?

Bend your knee outward like a frog

Which racial group has the highest prevalence of heart disease and stroke in the United States? 1. Blacks 2. Whites 3. American Indians 4. Mexican-Americans

Blacks

During an assessment of a 68-year-old man with a recent onset of right sided weakness, the nurse here's a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. What does this finding indicate?

Blood flow turbulence due to carotid stenosis

A 60-year-old is at the clinic for a " Cut on my right hand that looks infected." Which of these findings with the nurse expect on a physical examination? A. Right inguinal lymph nodes that are hard, fixed, and irregularly shaped B. Right inguinal lymph nodes that are firm in tinder and measure 1 cm in diameter C. Right epitrochlear lymph node that is firm and tender and measures 1 cm in diameter D. Right epitrochlear lymph node that is hard, fixed, and irregularly shaped

C. Right epitrochlear lymph node that is firm and tender and measures 1cm in diameter

Blood levels of which substance are the primary control respiration?

Carbon dioxide

The nurse is caring for a client who experienced a stroke. The nurse assesses the clients breathing is irregular, initially deep in rapid, and then tapering to shallow with a period of apnea. What time will the nurse use in documenting the clients breathing pattern?

Cheyne-Stokes breathing

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is <2 seconds. The nurse whoile

Consider this an expected finding and proceed with the evaluation

Patient reports having leg pain while walking that is relieved with rest. Based on this data, the nurse six packs which finding on inspection and palpation of this patient?

Cool feet with capillary refill of toes greater than three seconds

What with the nurse anticipate assessing when performing an examination of the lungs and thorax on a pregnant female during her 36th week of pregnancy?

Costal angle greater than non-pregnant state

The advanced practice nurse is performing at cardiovascular assessment on a 28 year old female client in the 30th week of pregnancy and detects allowed, easily heard S3 sound. What should be the nurses action?

Document this expected finding

The nurse is assessing a client thorax and percusses a dull percussion tone. What should be the nurses initial action?

Ensure that the nurses finger is not over a rib

When assessing an 88-year-old male client, the nurse can either see nor feel the apical impulse. The nurse recognizes that this is

Expected because of changes in the rib cage in the elderly

In the older adult client, which respiratory change requires no further assessment by the nurse?

Increased anteroposterior (AP) diameter

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism by which venous blood returned to the heart?

Intraluminal valves ensure unidirectional flow toward the heart

The nurse assesses capillary refill time of five seconds on an adult client. What should the nurse do next?

Investigate further for this delayed capillary refill

I'm palpating a patient's dorsalis pedis pulses, The nurse find the left one to be weak and the right one to be full and bounding. How should the nurse document this finding?

Left 1+, right 3+

When performing a cardiac assessment, what position should the nurse have the client assume to best auscultate for S3, S4, and mitral murmur?

Left lateral position

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

Which should the nurse do when assessing the carotid arteries of older patients with cardiovascular disease?

Listen with the bell of stethoscope to assess for bruits

The nurse palpates a thrill when assessing an adult clients chest. Which other associated finding with the nurse expect?

Loud, grade 6 cardiac murmur

The nurse assesses that a hospitalized client has new onset swelling, erythema, and increased warmth of the right leg. What should be the nurse's action in response to this finding?

Notify of the health care provider of the findings

The nurse is planning a health fair for older adults And wants to include information about lung health. Which topics should the nurse plan to include?

Obtaining an influenza immunization annually Smoking cessation for clients who smokes cigarettes Avoidance of secondhand smoke

Which Technique shit the nurse used to assess the position of the trachea?

Palpate the trachea just above the suprasternal notch

What is an expected physiologic change in blood vessels associated with the aging process?

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

A nurse determines that a patient jugular venous pressure is 3.5 cm. What additional data does the nurse expect to find?

Peripheral edema

What action does the nurse include before palpating the abdomen?

Place a pillow under the client's knees

What techniques of the nurses to best auscultate the second heart sound?

Place the diaphragm of the stethoscope at the base of the heart

The nurse preceptor is assisting a nursing student in completing a physical assessment on an adult client. Which action by the nursing student requires remediation by the nurse?

Places the stethoscope over the clients clothing to auscultate the lungs

Which pulse may be a challenge for a nurse to palpate?

Popliteal

When auscultating the lungs, where would the nurse expect to hear bronchovesicular sounds?

Posteriorly, between the scapulae

Which statement by the nursing student indicates a correct understanding of preload?

Preload is the venous return that builds during diastole

The mother of a three month old infant states that her baby has not been gaining weight. With further questioning the FNP finds that the infant falls asleep after nursing and wakes up after a short amount of time hungry again. What other information would the burse want to have?

Presence of dyspnea and cyanosis during feeding

Which blood vessels carry deoxygenated blood away from the heart?

Pulmonary arteries

A mother brings her three month old infant to the clinic for evaluation of a cold. When performing the physical assessment, the nurse notes that the child has nasal flaring aunt sternal and intercostals retractions. What should be the nurses next action?

Recognize that these are serious signs and alert the physician

When auscultating a patient's abdomen using the bell of the stethoscope, the nurse hears soft, low-pitched swooshing sounds over the right and left upper midline. What do these sounds indicate?

Renal artery bruits

The nurse is assessing a client for arterial deficit in the lower extremities by performing the color change test. After raising the feet 12 inches off the table and then having this client set up and then go to feet, what should the nurse observe?

Return of the color to the feet within 10 seconds or less

The nurse has percussed an area I've dullness over a client left lower lung and will further assess by using local residents tested. What instruction should the nurse provide to assess for bronchophony?

Say 99 each time you feel my stethoscope move

The most important technique is hen progressing from one auscultatory side in the thorax to another is

Side-to-side comparison

When assessing tactile fremitus in an individuals which of the following is the most important to consider?

Symmetry

The nurse is palpating for thrills in the precordial area. The nurse is using correct assessment technique when he/she uses

The base of the fingers

The health care provider documents that the client is experiencing paroxysmal nocturnal dyspnea. The nurse knows this means

The client awakens with difficulty breathing and a feeling of need for fresh air

Which valve does a nurse auscultate When the stethoscope is placed on the 4th to 5th intercostal space at the left of the sternal border?

Tricuspid

During diastole, blood pours from the atria into the ventricles, raising the ventricular pressure and causing the _________ and _______ valves to close. As the ventricles contract, ventricular pressure further increases and the _________ and _______ valves are forced open and blood is ejected from the ventricles

Tricuspid and mitral; pulmonic and aortic

What sound does the nurse expect to hear when percussing a patient's abdomen?

Tympany over all quadrants

Which actions should the nurse perform to assess for jugular venous distension?

Use tangential lighting to view pulsations Position the client at 30-45° head of the bed elevation Assess the client's right neck

What technique does a nurse use when performing deep palpation of a patient's abdomen?

Uses palmar surface of fingers to press down 4 to 8 cm

While reviewing a medical record, documentation of 4+ pitting Edema Of the right leg is noted. The best description of this type of edema is

Very deep pitting, indentation last longer than 20 seconds

During a cardiovascular assessment, the nurse knows that a thrill is

Vibration that is palpable

A client was diagnosed with chronic arterial insufficiency of the right lower leg. Which is most likely to be observed to the leg?

Weak, distal pulses, cool, pale, Thin and shiny skin

The nurse is assessing an adolescent client diagnosed with asthma. Which adventitious lung sound should the nurse anticipate auscultating as a result of narrowed bronchioles?

Wheezes

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

When the bronchial tree is obstructed