NURS 171 UNIT 2 DAVIS ADVANTAGE

The nurse is caring for a client with diabetic ketoacidosis, an acid-base disturbance. What type of breathing pattern should the nurse anticipate? Tachypnea Kussmaul's breathing Cheyne-Stokes respiration Biot's breathing

Kussmaul's breathing

Where should the nurse assess skin color changes in the dark-skinned patient? 1) Elbow 2) Any exposed area 3) Oral mucosa 4) Behind the knee

Oral mucosa

A client with pulmonary hypertension and right-sided heart failure has conversational dyspnea and shortness of breath. What is the first action the nurse should take? 1) Review and implement the primary care provider's prescriptions for treatments. 2) Perform a quick physical examination of breathing, circulation, and oxygenation. 3) Gather a thorough medical history, including current symptoms, from the family. 4) Administer oxygen to the patient through a nasal cannula.

Perform a quick physical examination of breathing, circulation, and oxygenation.

The nurse is performing a painless, noninvasive procedure to measure SaO2. Which procedure is it? Incentive spirometry Arterial blood gas (ABG) measurement Capnography Pulse oximetry

Pulse oximetry

What should the nurse use to assess skin temperature? 1) Dorsum of the hand 2) Pad of the fingertip 3) Palm of the hand 4) Dorsum of the wrist

Dorsum of the hand

Which assessment question helps assess immediate memory? 1) "How did you get to the hospital today?" 2) "Can you repeat the numbers 2, 7, 9 for me?" 3) "Do you recall the three items I mentioned earlier?" 4) "What was your birth date including the year?"

"Can you repeat the numbers 2, 7, 9 for me?" Rationale: The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly.

The nurse provides client education regarding hypertension prevention and management. Which statement indicates that the client understands the instructions? 1) "I don't have to worry if my blood pressure is high once in a while." 2) "I guess I will have to make sure I don't drink too much water." 3) "I can lose some weight to help lower my blood pressure." 4) "I will need to reduce the amount of milk and other dairy products I consume."

"I can lose some weight to help lower my blood pressure."

A client in labor after 32 weeks' gestation is eager to deliver. Which client statement indicates that teaching provided about fetal development was effective? 1) "The baby's lungs are well developed now, but he will be at increased risk for SIDS if I deliver early." 2) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." 3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." 4) "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

"If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." Rationale: Premature infants (younger than 33 weeks' gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open.

The home care nurse visits a client who wears oxygen at bedtime. She smells cigarette smoke when entering the home. What should she say to the client? "That's a strange smell; I wonder what it could be." "Have you been smoking? You shouldn't with oxygen present." "Have you been wearing your oxygen, or is it turned off?" "It smells like someone has been smoking in here. Do you realize that oxygen is highly combustible?"

"It smells like someone has been smoking in here. Do you realize that oxygen is highly combustible?"

The nurse is counseling a 17-year-old girl on smoking cessation. What should the nurse include when teaching this client? Select all that apply. 1) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 2) "Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful." 3) "Plan a time to quit when you will not have many other demands or stressors in your life." 4) "Reward yourself with an activity you enjoy when you quit smoking." 5) "Spend time with friends who do not smoke."

"Keep healthy snacks or gum available to chew instead of smoking a cigarette." "Plan a time to quit when you will not have many other demands or stressors in your life." "Reward yourself with an activity you enjoy when you quit smoking." "Spend time with friends who do not smoke."

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist. Which would be the best response to his statement? 1) "You should quit so your family does not get sick from exposure to secondhand smoke." 2) "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." 3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs." 4) "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

"Once you stop smoking, your body will begin to repair some of the damage to your lungs." Rationale: The nurse's response should focus on correcting the patient's misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. The coughing then subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. DO NOT USE SCARE TACTICS

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which instruction would be most important for the nurse to include? 1) "Be sure to put mittens on the baby." 2) "Layer the infant's clothing." 3) "Place a cap on the infant's head." 4) "Put warm booties on the baby."

"Place a cap on the infant's head." Rationale: All interventions are correct, but because of the many blood vessels close to the skin surface in the head, infants lose approximately 30% of their body heat through the head. Therefore, to prevent heat loss, it is most important to cover the head.

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." What would be the nurse's best response? 1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your healthcare provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."

"Your vital signs are stable, but there are other things to assess."

A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. How should the nurse document this finding? 1) Trace edema 2) +1 edema 3) +2 edema 4) +3 edema

+3 edema Rationale: +1: 2 mm depression; rapid return of skin to position. +2: 4 mm depression that disappears in 10-15 seconds. +3: 6 mm depression that lasts 1-2 minutes. Area appears swollen. +4: 8 mm depression that persists for 2-3 minutes. Area is grossly edematous.

Which factor influences normal lung volumes and capacities? Select all that apply. 1) Age 2) Race 3) Body size 4) Activity level 5) Gender

Age Body size Activity level Gender

A client's vital signs at the beginning of the shift are oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? 1) 62 2) 82 3) 102 4) 122

102 Rationale: The pulse rate tends to increase about 10 beats/min for each degree Fahrenheit of temperature elevation. The reasons are that in response to the fever (1) the metabolic rate increases and (2) periperipheral vasodilation occurs, causing a decrease in blood pressure. The body then causes the heart to beat faster to compensate for the decrease blood pressure.

Which blood pressure has a pulse pressure within normal limits? Select all that apply. 1) 104/50 mm Hg 2) 120/62 mm Hg 3) 120/80 mm Hg 4) 130/86 mm Hg 5) 140/98 mm Hg

120/80 mm Hg 130/86 mm Hg

When testing near vision, the nurse should position printed text how many inches away from the patient? 1) 20 2) 18 3) 16 4) 14

14 Rationale: A client with normal near vision will be able to read the newsprint from a distance of 35.5 cm (14 in.)

Which factors impact a client's normal body temperature? Select all that apply. Age Gender Exercise Environment Recent intake

Age Gender Exercise Environment Rationale: Recent intake is suggesting hot/cold beverages instead of food intake.

An individual begins grasping for air and makes an unusual high-pitched, harsh, crowing sound. What could be occurring? Airway obstruction Asthma attack Pneumonia Croup

Airway obstruction

A client's average normal temperature is 98°F. Which temperature would be expected during the night in a healthy young adult client who does not have a fever, inflammatory process, or underlying health problems? 1) 97.2°F 2) 98.0°F 3) 98.6°F 4) 99.2°F

97.2°F Rationale: The lowest temperature occurs during sleep (usually at night) when the metabolic rate is lowest. Temperature normally increases throughout the day until it peaks in the early evening.

The nurse assists the client to the restroom. Upon returning to bed, the client says he has a throbbing headache and feels chilled. Which priority vital signs should be evaluated? Select all that apply. Radial pulse Respiratory rate Tympanic temperature Apical pulse Blood pressure

?

As the nurse is placing the oxygen, she reflects on the percentage of oxygen being delivered via nasal cannula (NC) at 2 L. What would be the correct amount? 21% 24% 28% 32% 36%

28% Rationale: Room air oxygen at sea level is 21%. 1 L/NC = 24%; 2 L/NC = 28%; 3 L/NC = 32%; 4 L/NC = 36%, etc. When delivering oxygen per nasal cannula, anything above 3 L/NC should be humidified to prevent drying of the mucous membranes of the nasal passage. The nurse should never administer more than 6 L/NC.

Which is an abnormal capillary refill finding that the nurse should report? 1) 1 second 2) 2 seconds 3) 3 seconds 4) 4 seconds

4 seconds Rationale: Normal capillary refill is < 2 to 3 seconds.

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding? 1) 5: Normal 2) 4: Slight weakness 3) 3: Weakness 4) 2: Poor ROM

4: Slight weakness Rationale: 5 - Active motion against full resistance = Normal 4 - Active motion against some resistance = Slight weakness 3 - Active motion against gravity = Weakness 2 - Passive range of motion =Poor range of motion 1 - Slight flicker of contraction = Severe weakness 0 - No muscular contraction = Paralysis

The nurse documents in the medical record of a client the absence of bowel sounds. How long should the nurse listen to the abdomen prior to documenting this finding? 1 full minute 3 full minutes 5 full minutes 10 full minutes

5 full minutes

The nurse instructs the mother of a toddler on safety. What information about the toddler's developmental stage and factors that influence oxygenation should the nurse include? Select all that apply. 1) Frequent, serious respiratory infections 2) Airway obstruction from aspiration of small objects 3) Drowning in small amounts of water around the home 4) Development of asthma 5) Develop shortness of breath with extreme activity

Airway obstruction from aspiration of small objects Drowning in small amounts of water around the home

The parents and their toddler present to the clinic for a well-child check-up. Which differences would the nurse incorporate into the assessment since the client is a child? Select all that apply. Allow the toddler to make choices. Let the child play with the equipment. Administer needed immunizations last. Hold the toddler against the parent's chest. Promote and support the child's independence.

Allow the toddler to make choices.. Administer needed immunizations last.

A child has an inflamed epiglottis from a viral infection, causing stridor and partially blocking the flow of air. Which type of breathing problem is present? Altered infection Altered breathing pattern Altered gas exchange Altered airway

Altered airway

A client recovering from a respiratory infection is concerned about a new onset of diarrhea. What should the nurse assess in this client? 1) Last use of steroids 2) Amount of vitamin C ingested 3) Frequency of decongestant use 4) Use of over-the-counter antitussives

Amount of vitamin C ingested Rationale: Vitamin C in daily doses of 200 mg or more has not been found to prevent colds, but it has been shown to reduce the length and severity of symptoms. In amounts of 2,000 mg, it may cause diarrhea and gas.

Which statement is accurate about nasotracheal suctioning? Select all that apply. 1) Apply suction for no longer than 10 to 15 seconds during a single pass. 2) Apply suction while inserting and removing the catheter. 3) Reapply oxygen between suctioning passes for ventilator patients. 4) Gently rotate the suction catheter as you remove it. 5) Allow intervals of at least 30 seconds between suctioning.

Apply suction for no longer than 10 to 15 seconds during a single pass. Gently rotate the suction catheter as you remove it. Allow intervals of at least 30 seconds between suctioning.

An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client's lower legs. Which condition does this finding suggest? 1) Venous insufficiency 2) Hyperthyroidism 3) Arterial insufficiency 4) Dehydration

Arterial insufficiency Rationale: Peripheral arterial insufficiency is associated with smooth, thin, shiny skin with little to no hair.

At last measurement, the client's vital signs were: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs were: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should be the nurse's first intervention at this time? 1) Ask the client whether he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 3) Ask the client whether he is feeling chilled. 4) Take the temperature by a different route.

Ask the client whether he has had a warm drink in the last 30 minutes.

The nurse notes that a client has a prescription for a peak expiratory flow meter. For which health problem should the nurse prepare teaching for this client? 1) Asthma 2) Pneumonia 3) Emphysema 4) Pulmonary edema

Asthma Rationale: Peak expiratory flow rate (PEFR) measures the amount of air that can be exhaled with forcible effort. Patients with asthma use PEFR monitoring to detect subtle changes in their condition, often before symptoms occur.

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. With what should the nurse realize this finding is associated? 1) Low albumin levels 2) Zinc deficiency 3) Renal disease 4) Bacterial endocarditis

Bacterial endocarditis Rationale: Splinter hemorrhages, which are small hemorrhages under the nailbed. They are associated with bacterial endocarditis or trauma, a complication of IV drug abuse.

Which abnormal laboratory value is associated with icteric sclerae? 1) Bleeding time 2) Bilirubin 3) Hemoglobin 4) Glucose

Bilirubin Rationale: icteric sclerae refers to yellowed (white parts of the) eyes

What are the primary vital signs of the nursing assessment? Select all that apply. Blood pressure Pulse Pulse oximetry Respiratory rate Temperature

Blood pressure Pulse Respiratory rate Temperature

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1) Blood pressure decreases less than heart rate and respiratory rate. 2) Respiratory rate remains fairly stable throughout a person's life. 3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause. 5) Body temperature increases with aging.

Blood pressure increases; heart rate and respiratory rate decline. Men have higher blood pressure than women until after menopause.

While palpating Mrs. Wong's pulse, you find a rate of 40 beats/min. This finding is _________. Tachypnea Tachycardia Bradypnea Bradycardia

Bradycardia

Which information provides the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions

Breath sounds, vital signs, and pulse oximetry before and after suctioning

Which statement best describes the procedure used to assess capillary refill? 1) Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 2) Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 3) Tap on the skin with short strokes from your fingers. 4) Lift a fold of skin and allow it to return to its normal position.

Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color.

Which blood level normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate 4) Carbon dioxide

Carbon dioxide Rationale: Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs.

During an assessment, the nurse notices that a client's breathing pattern follows a cycle of progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which appropriately describes this respiratory pattern? Tachypnea Kussmaul's breathing Cheyne-Stokes respiration Biot's breathing

Cheyne-Stokes respiration

A client with a closed head injury has a respiratory pattern that progressively increases and then decreases in depth, followed by a period of apnea. What is this client's breathing pattern? 1) Biot's breathing 2) Kussmaul's respirations 3) Sleep apnea 4) Cheyne-Stokes respirations

Cheyne-Stokes respirations

The nursing instructor notices a client who is in pain yet does not have a pulse oximeter in use, and suggests to the student that one should be attached. Why? Clients in pain tend to breathe shallowly, which increases the risk for atelectasis. Oxygen levels should always be monitored in clients experiencing high levels of pain. Kussmaul's respirations are typical of clients experiencing increased levels of pain. Pain triggers Biot's respirations, which cause apnea.

Clients in pain tend to breathe shallowly, which increases the risk for atelectasis. Rationale: Atelectasis Anything that reduces ventilation (e.g., tumor, obstructed airway) can cause atelectasis, or alveolar collapse.

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. Which action is the most important for the nurse at this time? 1) Compare the left pedal pulse with the right pedal pulse. 2) Count the client's respiratory rate for 1 full minute. 3) Take the blood pressure in the arm without an IV. 4) Take an oral temperature with an electronic thermometer.

Compare the left pedal pulse with the right pedal pulse. Rationale: For a client having surgery on the leg, the most important data would be whether the circulation has been compromised because of the surgery. This can be done only by comparing one leg with the other.

Which factors should the nurse incorporate into the assessment of an older client according to the acronym SPICES? Select all that apply. Seizures Confusion Incontinence Skin breakdown Evidence of falls Problems with mobility

Confusion Incontinence Skin breakdown Evidence of falls

Which procedure technique has the most effect on the accuracy of an apical pulse count? 1) Counting the rate for 1 full minute 2) Exposing only the left side of the chest 3) Determining why assessment of apical pulse is indicated 4) Using your ring finger to palpate the intercostal spaces

Counting the rate for 1 full minute Rationale: Apical pulse is generally indicated for patients with cardiac conditions or who are taking cardiac medications. Often they have irregular heartbeats or slow rates. A more accurate count is obtained when such heartbeats are counted for a full minute.

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. What should the nurse realize this finding indicates? 1) Tactile fremitus 2) Egophony 3) Bronchophony 4) Crepitus

Crepitus Rationale: Crepitus results from air leaking into the subcutaneous tissue. It is most likely to occur around wounds, central intravenous (IV) line sites, chest tubes, or a tracheostomy.

The nurse prepares a teaching session on blood pressure for a group of nursing students. What should the nurse explain can falsely elevate the blood pressure measurement? Select all that apply. 1) Cuff that is too wide 2) Cuff that is too narrow 3) Mild to moderate pain present 4) Measuring after the client smokes 5) Measuring after a client ambulates

Cuff that is too narrow Mild to moderate pain present Measuring after the client smokes Measuring after a client ambulates Rationale: Too wide a cuff decreases blood pressure. Too narrow a cuff increases blood pressure. Mild to moderate pain can increase blood pressure. Tobacco use stimulates and increases blood pressure. Exercise stimulates and increases blood pressure.

The nurse assesses a client's vital signs. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases

Decreased blood pressure (BP) after standing up Rationale: A drop in the client's blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated.

An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient's tongue, she notes that it appears dry and furry. What does this finding indicate to the nurse? 1) Fungal infection 2) Dehydration 3) Allergy 4) Iron deficiency

Dehydration Rationale: A dry, furry tongue—associated with dehydration.

The nurse is considering modifications to the physical exam for various age groups. Which would be appropriate considerations? Select all that apply. Demonstrate the procedure on the preschooler's doll first. Develop rapport with the school-age child. Assess the older adult's ability to perform activities of daily living. Provide privacy for the adolescent. Have a parent hold the infant.

Demonstrate the procedure on the preschooler's doll first. Develop rapport with the school-age child. Assess the older adult's ability to perform activities of daily living. Provide privacy for the adolescent. Have a parent hold the infant.

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. What should this finding indicate about the client's pulses? 1) Bounding 2) Normal 3) Full 4) Diminished

Diminished Rationale: Describe pulse amplitude on a scale of 0 to 4: 0 =Absent: Pulse cannot be felt. 1 =Weak (thready): Pulse is barely palpable and can be easily obliterated by finger pressure. 2 =Normal quality: Pulse is easily palpated, not weak or bounding, obliterated by finger pressure. 3 =Full: Pulse is easily felt with little pressure; not easily obliterated. 4 =Bounding: Forceful, obliterated only by strong finger pressure.

Which information in a client's health history might indicate a risk for primary hypertension? 1) Consumes a high-protein diet 2) Drinks three to four beers every day 3) Has a family history of kidney disease 4) Does not engage in physical exercise

Drinks three to four beers every day Rationale: Heavy alcohol consumption, age, race, high-sodium diet, tobacco use, family history of hypertension, and high cholesterol levels put a client at risk for primary hypertension.

What should be evaluated when assessing for type of cough? Select all that apply. Dry, productive, or hacking When does it occur How long has client had cough What makes it worse or better Fever Irritant exposure

Dry, productive, or hacking When does it occur How long has client had cough What makes it worse or better

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which response indicates to the nurse that the medication is effective? 1) The amount of sputum decreases with each dose administered. 2) Cough is completely suppressed, and the patient is able to sleep through the night. 3) Dry, unproductive cough is reduced, but voluntary coughing is more productive. 4) Involuntary coughing produces large amounts of thick yellow sputum.

Dry, unproductive cough is reduced, but voluntary coughing is more productive. Rationale: Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep.

Which intervention is likely to reduce the risk of postoperative atelectasis? Select all that apply. 1) Administer bronchodilators. 2) Apply low-flow oxygen. 3) Encourage coughing and deep breathing and coughing. 4) Administer pain medication. 5) Assist to move and reposition in bed.

Encourage coughing and deep breathing and coughing. Administer pain medication. Assist to move and reposition in bed.

A client with a nagging chronic cough has no symptoms other than shortness of breath. Upon assessment, the client mentions having a spouse who is a heavy smoker and smokes approximately two packs per day. When educating the client on the increased risk of cancer, the client quickly states, "I don't breathe in that much smoke." What information should be given to the client? Select all that apply. Even small amounts of smoke cause damage to the vessels and abnormal heart rate. Secondhand smoke leads to increased risk for stroke and increased death from cancer. There is no safe level of exposure to secondhand smoke. Once a person stops smoking, the body begins to repair itself. Smoke inhalation can lead to emphysema and COPD.

Even small amounts of smoke cause damage to the vessels and abnormal heart rate. Secondhand smoke leads to increased risk for stroke and increased death from cancer. There is no safe level of exposure to secondhand smoke. Smoke inhalation can lead to emphysema and COPD.

A client's radial pulse is full and bounding. Which nursing diagnosis should the nurse select to address this clinical finding? 1) Excess fluid volume 2) Deficient fluid volume 3) Decreased cardiac output 4) Ineffective tissue perfusion

Excess fluid volume

Gas exchange that occurs in the alveoli-capillary membrane is referred to as what type of respiration? External Internal Hyperventilation Hypoventilation

External Rationale: External Respiration (Alveolar-capillary gas exchange) occurs in the alveoli of the lungs: Oxygen (O2) diffuses across the alveolar-capillary membrane into the blood of the pulmonary capillaries. Carbon dioxide (CO2) diffuses out of the blood and into the alveoli to be exhaled (Fig. 36-4).

Which findings are specific indicators of hypoxia? Select all that apply. 1) Feelings of anxiety 2) Crackles in the lung bases 3) Increased heart rate 4) Improved breathing in upright position 5) Cyanosis of the tongue

Feelings of anxiety Increased heart rate Cyanosis of the tongue

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1) Apply pressure to the mandible at the jaw. 2) Rub the patient's sternum. 3) Squeeze the trapezius muscle. 4) Gently shake the patient's shoulder.

Gently shake the patient's shoulder.

The nurse examines the site of a client's tuberculin skin test as being 5 mm induration and documents that the test is positive. Which information in the client's history did the nurse use to make this clinical determination? 1) HIV positive 2) Type 2 diabetes mellitus 3) Lives in a skilled nursing facility 4) Recent immigrant to the United States

HIV positive Rationale: Tuberculin Skin Testing is widely used to detect exposure and antibody formation to the tubercle bacillus. An induration of 5 mm is considered positive for the tuberculin skin test for the client who is HIV positive.

The nurse is assessing the lungs of a client and notes slight crackles as well as regular breath sounds in both lung fields. The client appears to be in no respiratory distress and has an oxygen saturation of 98% on room air. What should be the nurse's first intervention? Have the client cough and listen again. Notify the primary health care provider. Administer a nebulizer breathing treatment. Document the findings in the medical record.

Have the client cough and listen again.

The nurse is caring for a patient who is experiencing dyspnea. Which position would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

Head of bed elevated 80°

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. What should this finding indicate to the nurse? 1) Heart failure 2) Coronary artery disease 3) Hypertension 4) Pulmonic stenosis

Heart failure Rationale: A split sound at either S1 or S2 may occur if there is a delay in closure of one of the valves. An S3 that does not disappear with position change is abnormal and represents heart failure or volume overload. An S4 may be heard in adults with coronary artery disease, hypertension, and pulmonic stenosis.

A patient's jugular venous pressure measures 5 cm. What should this finding indicate to the nurse? 1) A normal finding 2) Hypovolemia 3) Heart failure 4) Dehydration

Heart failure Rationale: Expected findings: Normal JVP is < 3 cm. Abnormal findings: Elevated JVP (in congestive heart failure [CHF] or constricted flow into the right side of the heart); low JVP (in hypovolemia)

The nurse is caring for a patient experiencing dyspnea. Which position would be most effective to support ventilation? Supine High Fowler's Side-lying Low Fowler's

High Fowler's

A female patient has excessive facial hair. How should the nurse document this finding? 1) Alopecia 2) Albinism 3) Hirsutism 4) Lanugo

Hirsutism Rationale: Hirsutism is excess facial or trunk hair may be due to endocrine disorders or steroid use.

For which patient would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? 1) Recovering from abdominal surgery 2 hours ago 2) Experienced a fractured hip yesterday 3) Dehydrated from vomiting 4) History of heart and lung disease

History of heart and lung disease Rationale: Conditions that require assessment of pulse deficit include digitalis therapy and blood loss, cardiac or respiratory disease, and other conditions that affect oxygenation status.

Which disorder can cause an increase in the basal metabolic rate (BMR) and thus raises body temperature? Hypertension Hyperlipidemia Hypothyroidism Hyperthyroidism

Hyperthyroidism

An individual has recently moved from the coast of Florida to the Rocky Mountains in Colorado. What can be expected to physiologically occur over time to help facilitate oxygenation? Select all that apply. Increased RBC production Increased lung volume and pulmonary vasculature Increased ventilation Arterial chemoreceptors stimulate ventilation Irritation of the membranous lining of the lungs

Increased RBC production Increased lung volume and pulmonary vasculature Increased ventilation Arterial chemoreceptors stimulate ventilation Tip: A change in altitude does not decrease the percentage of molecules of oxygen in the air; however, the molecules are more spread out.

A client is coughing and has bilateral rhonchi throughout the lung fields. Which nursing diagnosis is most appropriate for these assessment findings? 1) Impaired Gas Exchange 2) Ineffective Airway Clearance 3) Ineffective Breathing Pattern 4) Impaired Spontaneous Ventilation

Ineffective Airway Clearance

The nurse notes that a client's respiratory rate is 30 and irregular. Which nursing diagnosis should be identified to help guide this client's care? 1) Anxiety 2) Altered oxygenation level 3) Risk for poor oxygenation 4) Ineffective breathing pattern

Ineffective breathing pattern

A client presents with cyanosis, tachypnea, grunting, and reports that he or she cannot breathe. What is the immediate response the nurse should take? Ask questions about symptoms while performing a quick examination. Ask extensive questions about occupation factors, smoking habits, and living environment. Complete a full assessment including demographic data, health history, respiratory-cardiovascular history, environmental history, and lifestyle. Inspect to observe respiratory patterns and signs of respiratory distress.

Inspect to observe respiratory patterns and signs of respiratory distress.

A patient has just had a chest tube inserted to dry-seal suction drainage. Which is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patient's arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing.

Keep the drainage system lower than the insertion site.

A student nurse enters the room of a client and begins the assessment while the registered nurse observes. Which action made by the student nurse requires correction by the registered nurse? Ask any visitors to leave the room. Turn on the lights in the client's room. Leave the door open to allow lighting. Gather all supplies prior to entering the room.

Leave the door open to allow lighting. Tip: Physical examination requires you to observe and touch the client's body, so privacy is essential.

Which factors affect respiration? Select all that apply. Decreased serum potassium levels Level of carbon dioxide tension in the blood Changes in pressure within the thoracic cavity Central chemoreceptors in the medulla and pons Peripheral chemoreceptors located in the carotid and aortic bodies

Level of carbon dioxide tension in the blood Central chemoreceptors in the medulla and pons Peripheral chemoreceptors located in the carotid and aortic bodies

While assessing an older adult patient, the nurse notes clubbing of the fingers. What does this finding indicate to the nurse? 1) Fungal infection 2) Malnutrition 3) Iron deficiency 4) Long-term hypoxia

Long-term hypoxia Rationale: Clubbing, in which the nail plate angle is 180° or more, is associated with long-term hypoxic states, such as occur with chronic lung disease.

For which condition is obesity associated with a higher risk of conditions that affect the pulmonary and cardiovascular systems? Select all that apply. 1) Reduced alveolar-capillary gas exchange 2) Lower respiratory tract infections 3) Sleep apnea 4) Hypertension 5) Dyspnea on exertion

Lower respiratory tract infections Sleep apnea Hypertension Dyspnea on exertion

During a clinic interview, a client states experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1) Ask the client when in the day dizziness occurs. 2) Help the client to assume a recumbent position. 3) Measure both heart rate and blood pressure with the client standing. 4) Measure vital signs with the client supine, sitting, and standing.

Measure vital signs with the client supine, sitting, and standing. Rationale: Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension.

The nurse is encouraging a client to cough and deep breathe as well as use the incentive spirometer. She also performs chest physiotherapy twice a day. What is the purpose of these interventions? Reduce infection rate Prevent aspiration Mobilize secretions Increase oxygen levels

Mobilize secretions

In evaluating a client's blood pressure for hypertension, what is the most important action for the nurse to take? 1) Use the same type of manometer each time. 2) Auscultate all five Korotkoff sounds. 3) Measure the blood pressure in both arms. 4) Monitor the blood pressure for a pattern.

Monitor the blood pressure for a pattern. Rationale: Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions.

A client's pulse oximetry reading is 90%. What action should the nurse take first? 1) Raise the head of the bed. 2) Prepare to administer oxygen. 3) Notify the healthcare provider. 4) Move the sensor to another area.

Move the sensor to another area. Rationale: The nurse should relocate the sensor to another body area. The hands may be cold or the elbow might be bent. The earlobe should be attempted before implementing any other actions.

The nurse hears some adventitious heart sounds when auscultating the anterior chest. What could the nurse be hearing? Select all that apply. Murmur Third heart sound Second heart sound First heart sound Fourth heart sound

Murmur Third heart sound Fourth heart sound

Which oxygen delivery method can deliver the highest Fio2? Nonrebreather mask Partial rebreather mask Nasal cannula Tent mask

Nonrebreather mask

The nurse assesses a 4-year-old child's vision as 20/40. What should the nurse realize this finding indicates? 1) Myopia 2) Hyperopia 3) Normal 4) Presbyopia

Normal Rationale: Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal, so of course 20/40 is normal as well.

The nurse notes a small pulsation at the fifth intercostal space midclavicular line. How should the nurse document this finding? 1) Thrill 2) Murmur 3) Normal finding 4) Heave

Normal finding

A patient with COPD has a pulse oximetry reading of 97%. What other finding would indicate adequate tissue and organ oxygenation? Select all that apply. 1) Normal urine output 2) Strong peripheral pulses 3) Clear breath sounds bilaterally 4) Normal muscle strength 5) Orientation

Normal urine output Strong peripheral pulses Normal muscle strength Orientation

The nurse is assessing a client with congestive heart failure and notes 3+ bilateral pitting pedal edema. The nurse is unable to palpate the pedal pulses. What would be the best intervention? Document that the pedal pulses cannot be obtained. Ask another nurse to verify the lack of pedal pulses. Obtain a portable Doppler and check for pedal pulses. Notify the primary health-care provider of a lack of pedal pulses.

Obtain a portable Doppler and check for pedal pulses.

A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1°F to 100.8°F to obtain an oral equivalent. 2) Add 2°F to 100.8°F to obtain a rectal equivalent. 3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.

Obtain a rectal temperature reading.

Which is the best term for the nurse to include in his or her assessment documentation to note that a client is unable to lie flat without becoming short of breath? Wheezes Crackles Dyspnea Orthopnea

Orthopnea

A client has a chest drainage system. What should the nurse include when teaching the client about this system? Select all that apply. 1) Perform frequent coughing and deep-breathing exercises. 2) Sit up in a chair but do not walk while the drainage system is in place. 3) Get out of bed without assistance as much as possible. 4) Immediately notify the nurse if experiencing increased shortness of breath. 5) Make sure the collection device is above the level of the chest tube insertion site.

Perform frequent coughing and deep-breathing exercises. Immediately notify the nurse if experiencing increased shortness of breath.

Which physiological processes occur when the hypothalamus is stimulated due to a client being warm? Select all that apply. Epinephrine release Peripheral vasodilation Perspiration Piloerection Shunting of blood away from the periphery

Peripheral vasodilation Perspiration Rationale: The other options occur when a person is cold

What nursing intervention should be applied for a client with pneumonia of the right lower lobe? Place on left side and elevate the foot of the bed. Place on right side and elevate the head of the bed. Place in Trendelenburg position. Place in Fowler's position.

Place on left side and elevate the foot of the bed. Rationale: This position will allow for the right lung to drain.

While a patient is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1) Clamp the chest tube close to the insertion site. 2) Set up a new drainage system and connect it to the chest tube. 3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4) Place the disconnected end nearest the patient into a bottle of sterile water.

Place the disconnected end nearest the patient into a bottle of sterile water.

When using sterile technique to perform tracheostomy care of a new tracheostomy, which action is correct? 1) Apply sterile gloves. 2) Place the patient in semi-Fowler's position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 × 4 gauze halfway through to make a dressing.

Place the patient in semi-Fowler's position, if possible. Rationale: Semi-Fowler's position promotes lung expansion and prevents back strain for the nurse.

Chest percussion and postural drainage would be an appropriate intervention for which condition? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

Pneumonia

Chest percussion and postural drainage would be an appropriate intervention for which conditions? Select all that apply. Pneumonia Cystic fibrosis Congestive heart failure Pulmonary edema Pulmonary embolus

Pneumonia Cystic fibrosis Congestive heart failure Pulmonary edema Rationale: Postural drainage is the use of positioning to promote drainage from the lungs. Postural drainage uses gravity to drain the lungs, so you will position the affected area uppermost so that secretions will drain down toward the large, central airways.

As the nurse prepares for a physical assessment, what should be considered? Select all that apply. Preparing the environment Preparing the paperwork Infection control Preparing the equipment Preparing the client

Preparing the environment Infection control Preparing the equipment Preparing the client

A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. How should the nurse document this finding? 1) Myopia 2) Diplopia 3) Presbyopia 4) Mydriasis

Presbyopia Rationale: Diminished near vision is known as presbyopia (far sightedness).

The nurse is caring for a young adult who presents to the emergency room with severe abdominal pain in the right lower quadrant. Which assessment technique should the nurse use to determine rebound tenderness? Inspect the abdomen for distension. Press in the abdomen and slowly release. Auscultate all four abdominal quadrants. Percuss the abdominal area for hyperresonance.

Press in the abdomen and slowly release.

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

Prevents air from leaking around the site Rationale: Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure.

A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85%, heart rate of 113 beats/min, and respiratory rate of 30 breaths/min. The client is restless, and crackles and rhonchi are auscultated over both lungs. Which action should the nurse take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patient's signs of fluid overload.

Provide endotracheal suctioning. Rationale: Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient's symptoms should subside once the airway is cleared.

A client experiences acute shortness of breath. Which noninvasive technique should the nurse use to assess this client's arterial oxygen saturation? 1) Pulse oximetry 2) Auscultate breath sounds 3) Count the respiratory rate 4) Arterial blood gas sampling

Pulse oximetry Rationale: Pulse oximetry is a noninvasive method of monitoring oxygenation with a device that measures oxygen saturation (an indication of the oxygen's being carried by hemoglobin in the arterial blood).

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply. 1) Blood pressure 110/64 mm Hg 2) Pulse rate 118 beats/minute 3) Respiratory rate 35 breaths/minute 4) Oral temperature 98.6°F (37°C) 5) Pulse oximetry reading 94% on room air

Pulse rate 118 beats/minute Respiratory rate 35

A client is brought in to the emergency room from a motor vehicle accident. The client reports a headache and some dizziness, but no mental status deficits. The client is admitted for observation and four hours later, the nurse notes the client is lethargic and restless. Based on these findings, what should the nurse assess next? Pupillary response Level of orientation Spontaneous speech Count backwards by "7s"

Pupillary response

Which intervention would be appropriate for a client who has a fever? Select all that apply. 1) Put an ice pack on the client's neck and axillae. 2) Provide the client a blanket when he is shivering. 3) Offer the client fluids to drink every 1 to 2 hours. 4) Measure the temperature using a tympanic thermometer. 5) Lower the head of the bed.

Put an ice pack on the client's neck and axillae. Offer the client fluids to drink every 1 to 2 hours.

What information is needed when assessing the respiratory vital signs? Select all that apply. Rate Depth Rhythm Effort Quality

Rate Depth Rhythm Effort

Which client would probably have a higher than normal respiratory rate? 1) Recovering from surgery and receiving a narcotic analgesic 2) Recovering from surgery and lost a unit of blood intraoperatively 3) Lived at a high altitude and then moved to sea level 4) Exposed to the cold and is now hypothermic

Recovering from surgery and lost a unit of blood intraoperatively Rationale: A reduction in hemoglobin from blood loss would increase the respiratory rate.

The client has had a fever, ranging from 99.8°F orally to 103°F orally, over the past 24 hours. How should the nurse classify this fever? 1) Constant 2) Intermittent 3) Relapsing 4) Remittent

Remittent Rationale: Remittent fevers fluctuate widely over a 24-hour period.

The nurse administers intravenous morphine sulfate to a patient for pain control. For which adverse effect should the nurse monitor this patient? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression

Respiratory depression

Premature babies are at higher risk for what respiratory problem? Respiratory distress syndrome Upper respiratory infection Asthma Airway obstruction

Respiratory distress syndrome Rationale: Premature Infants (less than 35 weeks' gestation) are at high risk for respiratory distress syndrome (RDS), which is characterized by widespread atelectasis (collapse of alveoli). This risk exists because premature infants: Do not have a fully developed alveolar surfactant system. Surfactant is the substance that keeps air sacs inflated for effective respiration. Have immature pulmonary circulation. Together with hypoventilation, this leads to hypercarbia (high CO2 blood levels) and hypoxemia.

When caring for a client with a fever, what should the nurse expect to be increased? 1) Urine output 2) Sensitivity to pain 3) Blood pressure 4) Respiratory rate

Respiratory rate Rationale: The metabolic rate increases with a fever, increasing a person's respiratory rate.

The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure, 107/66 mm Hg. Which findings are abnormal? Select all that apply. Respiratory rate Systolic blood pressure Temperature Diastolic blood pressure Pulse

Respiratory rate Temperature Pulse

Which assessment data best supports a report of severe pain in an adult client whose baseline vital signs are within an average normal range? 1) Oral temperature 100°F (37.8°C) 2) Respiratory rate 26 breaths/min and shallow 3) Apical heart rate 56 beats/min 4) Blood pressure 124/82 mm Hg

Respiratory rate 26 breaths/min and shallow

A client has a nursing diagnosis of Ineffective Breathing Pattern identified on the care plan. What should the nurse expect when assessing this client? 1) Coughing 2) Cold extremities 3) Adventitious breath sounds 4) Respiratory rate of 8 breaths/min

Respiratory rate of 8 breaths/min

For which adult client should the nurse make follow-up observations and monitor the vital signs closely? 1) Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg. 2) Oral temperature is 97.9°F in the morning and 99.8°F in the evening. 3) Heart rate was 76 beats/min before eating and 88 beats/min after eating. 4) Respiratory rate is 16 breaths/min when standing and 18 when lying down.

Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg. Rationale: Both blood pressures would be classified as prehypertension according to the JNC 7 Express guidelines. Body temperature normally increases during the course of a day. Heart rate increases for several hours after eating. Respiratory depth decreases when lying down, so it would be normal for the rate to increase; both rates are within normal limits.

Which test should the patient undergo when the Weber test is positive? 1) Romberg test 2) Rinne test 3) Pure tone audiometry 4) Tympanometry

Rinne test Rationale: Hearing involves transmission of sound vibrations and generation of nerve impulses along CN VIII. The Weber test assesses both aspects. Weber test if the vibration is louder in one ear. If the Weber test is positive, you will need to perform the Rinne test to assess the type of hearing problem. The Rinne test also uses a tuning fork to compare air conduction (AC) and bone conduction (BC). Normally AC is twice as long as BC

As Mr. Martin's oxygenation deteriorates, the nurse has an order to titrate pulse oximetry to keep it greater than 90%. Because Mr. Martin is currently at 6 L/NC (44% oxygen), what would be the best options for delivery of oxygen should the levels drop below 90%? Select all that apply. Simple mask Partial rebreather mask Nonrebreather mask Venturi mask Face tent

Simple mask Partial rebreather mask Venturi mask Face tent Rationale: A simple mask can deliver 40%-60% Fio2; partial rebreather mask delivers 50%-90% Fio2; Venturi mask delivers 24%-50% Fio2; and a face tent delivers 30%-55% Fio2. A nonrebreather mask delivers 70%-100% Fio2, which would be too large a jump from Mr. Martin's current delivery.

Which position is best for evaluating a client's posterior lung fields? Dorsal recumbent Lithotomy Sitting Supine

Sitting

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient's nails? 1) Soft, boggy nails 2) Brittle nails 3) Thickened nails 4) Thick nails with yellowing

Soft, boggy nails Rationale: Soft boggy nails are seen with poor oxygenation.

The nurse is performing an otoscopic examination on an adult patient. After having the patient tilt the head to the side not being examined and looking into the ear canal to make sure a foreign body is not present, what should the nurse do next? 1) Straighten the ear canal by pulling the pinna up and back. 2) Insert the speculum into the ear canal slowly. 3) Test the mobility of the tympanic membrane. 4) Straighten the ear canal by pulling the pinna down and back.

Straighten the ear canal by pulling the pinna up and back.

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply. 1) Rhythm of the pulses 2) Strength of the pulses 3) Bilateral equality of pulses 4) Rate compared with apical pulse 5) Location of the pulse

Strength of the pulses Bilateral equality of pulses Rationale: The quality of a pulse is only concerned with strength and equality.

What is the most common cause of infectious pharyngitis? Streptococcal pyogenes Staphylococcus aureus Influenza virus Respiratory syncytial virus

Streptococcal pyogenes Rationale: The pathogen that causes strep throat.

The nurse notes that the client is experiencing respiratory distress. Which assessment changes support this finding? Select all that apply. Eupnea Stridor Wheezing Grunting Nasal flaring

Stridor Wheezing Grunting Nasal flaring

In the assessment of the skin, the nurse should evaluate which components? Select all that apply. Tenderness Temperature Touch Texture Turgor and elasticity

Tenderness Temperature Texture Turgor and elasticity

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea? 1) Edema 2) Hyperhidrosis 3) Pallor 4) Tenting

Tenting Rationale: Tenting: Seen with dehydration or normal aging. It predisposes the patient to skin breakdown.

A client visits an urgent care center while on vacation in Colorado. The client reports difficulty breathing since arriving. Which factor most likely explains the client's dyspnea? The client is experiencing a sickle cell crisis. The high altitudes prevent oxygen from binding to hemoglobin. The client has consumed large amounts of caffeinated coffee. The client has underlying chronic obstructive pulmonary disease (COPD).

The high altitudes prevent oxygen from binding to hemoglobin.

Which are reasons for a nurse to perform a nursing assessment of a client? Select all that apply. To obtain baseline information To develop a plan for nursing care To evaluate effectiveness of interventions To receive reimbursement for services provided To determine the presence of disease and its pathology

To obtain baseline information To develop a plan for nursing care To evaluate effectiveness of interventions

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1) Avoid palpating the patient's abdomen. 2) Turn off the suction before auscultating bowel sounds. 3) Listen for bowel sounds for 2 minutes in each quadrant. 4) Percuss the abdomen before auscultating bowel sounds.

Turn off the suction before auscultating bowel sounds.

When teaching a client how to use a peak flow meter at home, what should be done if the reading falls within the yellow marker of the meter? Use a fast-acting bronchodilator. Immediately seek medical care. Take an antihistamine. Wait 10 minutes and complete the test again.

Use a fast-acting bronchodilator. Rationale: Peak flow meter: Green = All clear: Baseline peak flow —Peak flow is within 80% to 100% of personal best baseline. Treatment protocol calls for routine medication use. Yellow = Caution: Peak flow is 50% to 80% of usual or "normal" rate. Said another way, there is a 20% to 50% reduction in peak flow—This reading signals the onset of airway changes. Treatment protocols usually specify an increase in the dosage of maintenance medications, use of rescue therapies (e.g., fast-acting bronchodilators), or a call to the healthcare provider. These measures are designed to reverse acute exacerbations before they become severe. Red = Medical alert: Peak flow is less than 50% of personal best baseline. Severe reduction in peak flow. Treatment protocols usually specify immediate treatment with rescue medications and to seek emergency treatment if symptoms do not improve.

A patient with chronic obstructive pulmonary disease (COPD) is prescribed O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

Venturi mask Rationale: The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease.

What should the nurse do when obtaining a client's orthostatic blood pressure (BP)? Take the standing BP first. Perform these readings prior to the client eating. Wait 1 to 3 minutes in between each reading. Document the lowest BP reading.

Wait 1 to 3 minutes in between each reading.

The nurse enters the room of a client and, without the use of the stethoscope, can hear the client wheezing. How should the nurse document this finding in the medical record? Wheezes noted upon inspection. Wheezes noted upon percussion. Wheezes noted upon direct auscultation. Wheezes noted upon indirect auscultation.

Wheezes noted upon direct auscultation.

How should the nurse document high-pitched breath sounds produced by narrowed airways? 1) Rales 2) Crackles 3) Rhonchi 4) Wheezing

Wheezing Rationale: Narrowing of small airways by spasm, inflammation, mucus, or tumor High-pitched musical or squeaking sounds heard during inspiration or expiration.

Which of the following assessment findings would help confirm a diagnosis of asthma in a client? Wheezing on inspiration and expiration Stridor upon inspiration Increased forced expiratory volume Normal breath sounds but with retraction

Wheezing on inspiration and expiration Rationale: Wheezing—A musical sound produced by air passing through partially obstructed small airways. It is often heard in patients with asthma and lung congestion. Tip: Asthma clients experience increased airway resistance and will demonstrate signs of dyspnea.

Abdominal palpation should be avoided in a child who has which disorder? 1) Appendicitis 2) Wilms' tumor 3) Crohn's disease 4) Small bowel obstruction

Wilms' tumor Rationale: Caution: Do not palpate the abdomen if the client has a Wilms' tumor, a large diffuse pulsation, or a history of organ transplantation.

When measuring a blood pressure, which step is correct? Select all that apply. 1) Use a bladder that encircles 40% of the arm. 2) Wrap the cuff snugly around the client's arm. 3) Ask the client to hold the arm at heart level. 4) Have the client sit with feet flat on the floor. 5) Roll up a sleeve before applying the cuff.

Wrap the cuff snugly around the client's arm. Have the client sit with feet flat on the floor.

The nurse is documenting the vital sign assessment. Which statement would be a correct description? "Low-grade temperature, pulse regular and unlabored, respiration shallow." "Afebrile, radial pulse weak, respirations deep and regular." "Bounding temperature, regular pulse, unlabored respirations." "Hyperthermia, tachycardia, bradypnea." "Temperature thready, pulse normal, respirations irregular."

"Hyperthermia, tachycardia, bradypnea."

The nursing instructor asks students how they would assess the fifth vital sign. Which student would be correct? 1) "I would have the client rate her pain on a scale of 0 to 10." 2) "I would ask the client when she had her last bowel movement." 3) "I would take the client's pulse oximetry reading." 4) "I would interview the client about history of tobacco use."

"I would have the client rate her pain on a scale of 0 to 10."

The parent of an 18-month-old child is concerned because the child's legs are bowed. Which response by the nurse is appropriate? 1) "Your child will most likely require physical therapy." 2) "You should consider having your child seen by an orthopedic surgeon." 3) "This is a normal finding in children for 1 year after they begin walking." 4) "Your child is walking fine, so you don't need to worry."

"This is a normal finding in children for 1 year after they begin walking."

While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best? 1) "I'll ask the physician to look at the spot." 2) "Those spots are quite common and typically fade with time." 3) "You may want a plastic surgeon to look at that." 4) "That spot is benign so it's nothing you need to worry about."

"Those spots are quite common and typically fade with time." Rationale: Mongolian spots are benign, blue-black birthmarks that occur most commonly on the lower back and buttocks of African American, Hispanic, Native American, and Asian babies. They are the result of pigmented cells in the deeper areas of skin. Most fade by age 2 but can persist until early adolescence.

A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, what should the nurse anticipate the client's respiratory rate to be? 1) 16 2) 18 3) 20 4) 22

18 Rationale: For every degree Fahrenheit (0.6°C) the temperature falls, the respiratory rate may decrease up to 4 breaths per minute. The client's temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/min: 26 - 8 = 18 breaths/min. Keep in mind that this is an estimate and would vary depending on the patient's baseline health, current condition, age, and other factors.

The nurse is informing a group of unlicensed assistive personnel (UAP) about when it is appropriate for a vital sign assessment to be completed in an acute care facility. What responses would be correct? Select all that apply. At the beginning and end of each nurse's shift Upon admission to a clinical facility When the client's status changes When there is time available in the day More frequently after a procedure or surgery

?

Which statements about vital sign equipment are correct? Select all that apply. Blood pressure cuffs come in two sizes, large and small. A stethoscope is required to take a radial pulse. An axillary temperature is the most accurate. Vital sign equipment should be cleaned between each patient use. Electronic blood pressure monitors can be set to monitor and record BP at timed intervals and do not require the use of a stethoscope.

?

Which vital signs are considered normal? Select all that apply. Diastolic blood pressure of 91 mm Hg Apical pulse of 76 beats/min Systolic blood pressure of 145 mm Hg Respiratory rate of 22 breaths/min Rectal temperature of 99.1°F (37.3°C)

?

In which clients would the nurse find elevated pulse rates? Select all that apply. A 3-month-old infant A client with hypothyroidism A client taking digoxin (Lanoxin) A client with a temperature of 101.0°F A client with chronic obstructive pulmonary disease (COPD)

A 3-month-old infant A client with a temperature of 101.0°F A client with chronic obstructive pulmonary disease (COPD)

The nurse prepares to complete a focused physical assessment on a client with a chronic health problem. What should the nurse explain to the client as being the purpose of this assessment? Select all that apply. 1) Adds data to the database 2) Examines all body systems 3) Focuses on one body system 4) Focuses on a particular body part 5) Includes a health history interview

Adds data to the database Focuses on a particular body part

The nurse asks the patient to spread the fingers and then bring them together again. What is the nurse testing when asking the patient to bring the fingers together? 1) Abduction 2) Adduction 3) Flexion 4) Extension

Adduction

Which set of vital signs is within normal limits for a client at rest? 1) Infant: T 98.8°F (rectal), HR 160, RR 16, BP 120/54 2) Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 3) Adult: T 99.6°F (oral), HR 48, RR 22, BP 130/84 4) Older adult: T 98.6°F (oral), HR 110, RR 28, BP 170/95

Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68 Rationale: The infant's temperature is below normal for a rectal reading because the core temperature is approximately 1 degree higher than readings from other sites. The heart rate (HR) for an infant is high, the respiratory rate (RR) is low, and the blood pressure (BP) is high for the age. For the typical adult, the temperature is high, the HR is low, the RR is high, and the BP is elevated for the age. For the older adult, the temperature is high-end normal, the HR is high, the RR is high, and the BP is high for the age.

The nurse is working at a health fair providing blood pressure and pulse screenings. The nurse finds a young adult client has an apical pulse of 44 bpm. What would be the nurse's first action? Call 911 and notify emergency medical services (EMS). Have the client drink some water, then recheck the apical pulse. Ask the client if he or she is an athlete or runs every day. Instruct the client to make an appointment to see his or her health-care provider.

Ask the client if he or she is an athlete or runs every day.

The nurse is teaching a client how to use a portable blood pressure device to monitor blood pressure at home. What is the most important action for the nurse to take? 1) Ask the client to demonstrate the use of the blood pressure device. 2) Explain the importance of frequent calibration of the device. 3) Give the client a chart to record his blood pressure readings. 4) Provide written instructions of the information taught.

Ask the client to demonstrate the use of the blood pressure device.

A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? 1) Have the mother remain outside the room. 2) Ask the mother to remove the infant's clothing and diaper. 3) Weigh the infant wearing only the diaper. 4) Place the infant supine on the scale with his knees extended.

Ask the mother to remove the infant's clothing and diaper.

When should the nurse instruct a new mother to expect the anterior fontanel of her infant to fuse? 1) At about 8 weeks 2) At about 14 months 3) By 6 months of age 4) Before 1 year of age

At about 14 months Rationale: The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months.

Which actions should the nurse include when preparing to auscultate lung sounds in a client with congestive heart failure. Select all that apply. Auscultate each side and compare findings. Document the findings in the client's medical record. Ask the client to take slow breaths through his/her nose. Use the diaphragm of the stethoscope to listen to lung sounds. Listen to inspiration on one side and expiration on the other side.

Auscultate each side and compare findings. Document the findings in the client's medical record. Use the diaphragm of the stethoscope to listen to lung sounds.

Which assessment should the nurse perform if a palpable thyroid gland is present? 1) Illuminate the thyroid gland for the presence of fluid. 2) Auscultate the thyroid gland for bruits. 3) Percuss the thyroid gland for mass size. 4) Measure the thyroid gland to assess change.

Auscultate the thyroid gland for bruits. Rationale: Bruits are low-pitched sounds, best heard by the bell portion. In adults, a bruit suggests carotid stenosis, increased cardiac output secondary to fluid overload, use of stimulants, or hyperthyroidism.

Which disorder(s) might limit a patient's visual field? Select all that apply. 1) Diabetes 2) Advanced glaucoma 3) Peripheral vascular disease 4) Cataracts 5) Macular degeneration

Diabetes Advanced glaucoma Cataracts Macular degeneration

The nurse is preparing to perform a physical assessment. What should be included in the preparation of the client? Select all that apply. Confirm the client is not in pain. Establish rapport with the client. Consider developmental and cultural differences. Select a time when the client is relaxed and receptive. Alert the client before touching him or her.

Establish rapport with the client. Consider developmental and cultural differences. Select a time when the client is relaxed and receptive. Alert the client before touching him or her.

Bronchovesicular breath sounds are best heard over which area? 1) Midline over the trachea just below the larynx 2) Fourth intercostal space, in the midclavicular line 3) First and second intercostal spaces next to the sternum 4) At the base of the lungs near the diaphragm

First and second intercostal spaces next to the sternum Rationale: Heard over the 1st and 2nd ICS anteriorly and over the scapula posteriorly Medium-pitched, medium intensity, blowing sounds; inspiration and expiration are equal length and similar pitch.

A client presents to the emergency room and is diagnosed with an exacerbation of chronic obstructive pulmonary disease and is in distress. Which is the best type of assessment for the nurse perform for this client? Ongoing assessment System-specific assessment Focused-physical assessment Comprehensive physical examination

Focused-physical assessment Tip: A focused physical assessment (or examination) pertains to a particular topic, body part, or functional ability rather than overall health status, and it adds to the database created by the comprehensive assessment.

Which portion of the ear is responsible for maintaining equilibrium? 1) External ear 2) Inner ear 3) Middle ear 4) Ossicles

Inner ear Rationale: The inner ear is responsible for hearing and equilibrium.

The nurse is assessing the abdomen for a client returning from an abdominal surgery. Which assessment technique should the nurse perform first? Percussion Auscultation Inspection Palpation

Inspection

That nurse is performing a general survey for a newly admitted client. What should be included in this evaluation? Select all that apply. Mental state Appearance and behavior Vital signs Speech Dress, grooming, and hygiene

Mental state Appearance and behavior Vital signs Speech Dress, grooming, and hygiene

The nurse working in a clinic is preparing to assess a female adolescent. Which education should the nurse provide during the examination? Select all that apply. Minimize unhealthy food choices. Let the client help with the exam. Refrain from use of tobacco products. Allow the teenager to examine the equipment. Identify any risk factors for depression or suicide.

Minimize unhealthy food choices. Refrain from use of tobacco products. Identify any risk factors for depression or suicide. Tip: The adolescent is often self-conscious and introspective, and may wish to be examined without parents or siblings present, at least during the more personal aspects of the exam.

A client asks why the nurse needs so much time to complete a physical assessment. What should the nurse explain as the purposes for this type of assessment? Select all that apply. 1) Obtain baseline data 2) Identify nursing diagnoses 3) Screen for health problems 4) Evaluate teaching provided 5) Monitor previously identified problems

Obtain baseline data Identify nursing diagnoses Screen for health problems Monitor previously identified problems

Which gases are primarily exchanged during respiration? Select all that apply. Oxygen Chloride Nitrogen Hydrogen Carbon dioxide

Oxygen Carbon dioxide Tip: Special respiratory centers in the medulla oblongata and pons of the brain, along with nerve fibers of the autonomic nervous system, regulated breathing in response to minute changes in the concentration of oxygen (O2) and carbon dioxide (CO2) in the arterial blood.

The nurse is assessing the cardiovascular status of a client including pulses. Which action made by the nurse can place the client at risk for a stroke? Auscultate the carotids for bruits. Have the client lie on his or her left side. Locate and feel pulses with the thumbs. Palpate the carotid arteries simultaneously.

Palpate the carotid arteries simultaneously.

Assuming that all are accurate, which documentation about a patient's level of consciousness is best? 1) Patient is lethargic and slept when undisturbed. 2) Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. 3) Patient slept throughout the day, missing his meals and bath. 4) Patient appears to be tired as he slept throughout the day except when bathed.

Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the client's blood pressure and apical pulse. 4) Count the client's respiratory rate for 1 minute.

Request the client take a deep breath and cough. Rationale: Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds.

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1) Work rapidly to finish as quickly as possible. 2) Sequence the exam to limit position changes. 3) Demonstrate equipment before using it. 4) Omit portions of the exam that may be tiring.

Sequence the exam to limit position changes. Rationale: Assess the client's support system and ability to perform activities of daily living. Observe your client's energy level during the physical examination and provide rest periods if needed. Limit position changes. If the client tires easily, arrange the exam sequence to limit position changes. Difficulty assuming positions. Be aware that stiff muscles and arthritic joints may make it impossible for the client to assume certain positions. Adapt your techniques when examining older adults with impaired vision or hearing. Obtain feedback to be sure the patient is seeing and hearing you adequately. The acronym SPICES will help you to remember common problems of the elderly that require nursing intervention (Fulmer, 1991, 2007) and to focus your assessment as you perform a comprehensive physical examination: S—Sleep disorders P—Problems with eating or feeding I—Incontinence C—Confusion E—Evidence of falls S—Skin breakdown

The nurse notes ptosis in a patient who just arrived in the emergency department. What should the nurse realize this finding might indicate? 1) Hyperthyroidism 2) Stroke 3) Glaucoma 4) Macular degeneration

Stroke Rationale: Ptosis (drooping) may be caused by a stroke or neurological injury.

_____________ pressure is peak blood pressure against arterial walls. Brachial Mean Systolic Radial Diastolic

Systolic