NSG 3600 Exam 2

The nurse at the neighborhood family clinic is instructing a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"Take your blood pressure medications exactly as your doctor prescribed them."

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

30 to 55 breaths per minute

A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute

Which of the following patients is experiencing a disturbance in sensory perception as the primary problem rather than the etiology of another problem?

A patient who is experiencing acute confusion as a result of a drug interaction

A 57-year-old patient is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the patient has been unwilling to mobilize despite the nurse's teaching about the benefits of early mobilization following surgery. The nurse would recognize that the patient's prolonged immobility creates a risk for:

Atelectasis

49s The acute care nurse is assessing a newly admitted patient's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

Auscultation of a bruit

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Auscultation of the patient's heart murmur

A nurse assesses patient breath sounds for patients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? (Select all that apply.)

Blowing, hollow sounds; auscultated over the larynx and trachea Soft, low-pitched, whispering sounds heard over most of the lung fields Medium-pitched, medium-intensity, blowing sounds; auscultated over the first and second interspaces anteriorly and the scapula posteriorly

Upon auscultation of the patient's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?

Bronchial

Peripheral cyanosis and clubbing of the nails are symptoms of:

Chronic hypoxia

The nurse is informed while receiving a nursing report that the patient has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?

Confusion

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking

A weak, thready pulse found after the nurse palpates peripheral pulses may indicate what condition?

Decreased cardiac output

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment finding that should be documented and reported to the physician?

Decreased heart rate

You are working on a neurological unit and a physician asks you to perform a sensory experience assessment for a patient. You think about what things may place a person at risk for disturbed sensory perception and come up with which of the following? Choose all that apply.

Diminished senses related to advanced age Medications that alter certain senses Neuropathy related to diabetes mellitus

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask?

Do you work around loud noises at work?

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Eye opening Motor response Verbal response

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

Have you been experiencing any strange tastes or aftertastes lately?

An older adult patient is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the patient informs the nurse that, "I can't seem to catch my breath." The nurse has responded by repositioning the patient and measuring the patient's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the patient's:

Hemoglobin level

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

Hypoxia

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute

To assess a client's visual accommodation, the nurse has the client

Look at a close object, then at a distant object

Mr. Fields is a resident of a long-term care facility who has moderate hearing loss. When communicating with Mr. Fields, what should the nurse do?

Minimize background noises and ensure that lighting is adequate to see the nurse's face

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

Monitor the client's respiratory rate Check the symmetry of the client's chest Observe the breathing pattern and effort

A nurse in the emergency room is assessing a client for sensory perception dysfunction. Which of the following assessment techniques will the nurse use to gather objective data? Select all that apply.

Observation Diagnostic tests and procedures Physical assessment

While assessing a patient's neurological status, the nurse asks the patient to close his eyes. She then puts a teaspoon of peanut butter under his nose and asks him to identify the smell. The nurse is assessing which of the following senses?

Olfactory

You are palpating a patient's precordium. Which of the following is an expected clinical finding?

Palpable pulsation over the mitral area

The charge nurse is observing a new nurse perform an assessment of a patient's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene?

Palpation of both carotid arteries at the same time

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's:

Peripheral pulses

Which of the following statements accurately represents a characteristic of the third or fourth heart sound?

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults

You are preparing to assess a patient's cranial nerves. Which of the following techniques should you use to assess cranial nerve III?

Shine a bright light in the patient's eye and observe for bilateral pupillary response

When inspecting a patient's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression

The nurse is caring for a client with a dysrhythmia with a prescription for oxygen therapy. The client is concerned and asks the nurse, "Why am I getting oxygen when I came in with a heart problem?" What appropriate response would the nurse give this client?

The dysrhythmia interferes with the heart's circulation, leading to changes in oxygenation

The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields

For which conditions would the nurse assess to determine if a patient is suffering from sensory deprivation or overload? (Select all that apply.)

Thought disorganization Boredom Anxiety

A nurse is assessing the cranial nerves of a client who is recovering from Bell's palsy. Which of the following cranial nerves are important for the coordination of facial movement and reflex activity? Select all that apply.

VII IX V

The nurse assesses that the client has sensory impairment from longterm furosemide (Lasix) use. Which of the following actions will the nurse implement?

When communicating with the client, use a lower tone of voice