Fundamentals: Ch 20- NCLEX Questions

Match the breath sound with the appropriate description. 1) High-pitched sound heard on inspiration in infants 2) High-pitched, continuous musical sound 3) High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored, snoring sound 1)Crackles 2)Rhonchi 3)Stridor 4)Wheezes 5)Stertor

1 = 3; 2 = 4 3 = 1 4 = 2 5 = 5

Which of the following clients would have the most difficulty maintaining thermoregulation? 1) Young child playing soccer during the summer 2) Middle-aged adult snow skiing 3) Young adult playing golf on a hot day 4) Older adult raking leaves on a cold day

4) Older adult raking leaves on a cold day Rationale: Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control.

In caring for a client who has a fever, it would be important for the nurse to monitor for increased: 1) urine output 2) sensitivity to pain 3) blood pressure 4) respiratory rate

4) respiratory rate Rationale: The metabolic rate increases with a fever, increasing a person's respiratory rate. Urine output would more likely decrease, rather than increase, because of increased insensible loss and possible loss of intake because of loss of appetite. Change in pain sensation is not a symptom of a fever. Blood pressure is more likely to decrease with a fever because of peripheral vasodilation.

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

Answer: 1) "I would have the client rate her pain on a scale of 0 to 10." Rationale: Pain is considered to be the "fifth vital sign."

Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1) blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing. 2) rectal temperature was 97.9°F in the morning and 99.2°F in the evening. 3) heart rate was 76 before eating and is 60 after eating. 4) respiratory rate was 14 when standing and is 22 breaths/min after walking.

Answer: 1) blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 3) heart rate was 76 beats/min before eating and is 60 after eating Rationale: The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise.

The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: 1) pulse deficit 2) blood pressure 3) apical pulse 4) pulse pressure

Answer: 2) Blood pressure Rationale: If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures.

Which of the following information in the 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

Answer: 2) 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. Kidney disease is a cause of secondary hypertension.

Which of the following clients should have an apical pulse taken? A client who is: 1) febrile and has a radial pulse of 100 beats/min. 2) a runner who has a radial pulse of 62 beats/min. 3) an infant with no history of cardiac defect. 4) an elderly adult who is taking antianxiety medication.

Answer: 3) An infant with no history of cardiac defect Rationale: An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is < 60 or > 100 beats/ min, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children.

A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? 1) Axillary with an electronic thermometer 2) Oral with a glass thermometer 3) Rectal with an electronic thermometer 4) Tympanic with an infrared thermometer

Answer: 3) Rectal with an electronic thermometer Rationale: The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient's baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable.

The client has had a fever, ranging from 99.8°F orally to 103°F orally over the last 24 hours. The client's fever would be classified as: 1) constant 2) intermittent 3) relapsing 4) remittent

Answer: 3) remittent Rationale: Remittent fevers fluctuate widely over a 24-hour period. Constant fevers stay above normal with only slight fluctuations. Intermittent fevers alternate between normal or subnormal temperatures with periods of fever. Relapsing fevers alternate between periods of fever and periods of normal temperature; each phase lasting 1 to 2 days.

Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: 1) 118/68 mm Hg when standing and 110/72 mm Hg when lying down. 2) 140/80 mm Hg, HR 82 beats/min when sitting and 136/76 mm Hg, HR 98 beats/min when standing. 3) 126/72 mm Hg lying down and 133/80 mm Hg when sitting, and reports shortness of breath. 4) 146/88 mm Hg when lying down and 130/78 mm Hg when standing, and reports feeling dizzy.

Answer: 4) 146/88 mm Hg when lying down and 130/78 mm Hg when standing, and reports feeling dizzy Rationale: Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint.

The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: 1) crackles 2) rhonchi 3) stridor 4) wheezes

D) Stridor