Test 3 Practice Questions

4. When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision? A) Respirations have both autonomic and voluntary control. B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate. C) Temperature, pulse, and blood pressure are more volatile than respiratory rate. D) Tachypnea is an expected finding among hospitalized individuals.

Ans: A Feedback: Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

24. A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? A) Reading is erroneously high B) Reading is erroneously low C) Pressure on the cuff with be painful D) It will be difficult to pump up the bladder

Ans: A Feedback: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

25. Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent? A) Systolic pressure B) Diastolic pressure C) Auscultatory gap D) Pulse pressure

Ans: A Feedback: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.

16. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for? A) Stroke B) Anemia C) Cancer D) Infection

Ans: A Feedback: Hypertension is the most important risk factor associated with stroke.

12. A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate? A) Normal body temperature B) Decreased body temperature C) Increased body temperature D) Fluctuating body temperature

Ans: A Feedback: A person with normal body temperature is referred to as afebrile.

2. The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures? A) The nurse will use the arm with the highest reading. B) The nurse will use the arm with the lowest reading. C) The nurse will average the two blood pressures and document this average. D) The nurse will obtain a blood pressure on the client's leg.

Ans: A Feedback: An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10-mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.

1. Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following? A) A dysrhythmia B) Tachycardia C) Bradycardia D) Hypertension

Ans: A Feedback: An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.

34. While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurses's best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity.

Ans: A Feedback: Anti-embolism stockings are used to promote venous blood return to the heart and help in preventing blood clots. They often do help with edema in the legs, but they do not eliminate edema (nor is this their main goal). They do not provide a nonslip foot surface. If applied incorrectly they can increase the risk for impaired skin integrity.

6. A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen

Ans: A Feedback: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by decreased oxygen saturation measurement.

4. The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up? A) The client states that a mole on his forehead has become larger in recent months. B) Decreased skin turgor is evident when the skin is folded and then released. C) Small, round, red spots are present on the client's forearms bilaterally. D) There are some raised, brown areas on the backs of the client's hands.

Ans: A Feedback: Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).

2. The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? A) Encouraging the client to consume two to three quarts of clear fluids daily B) Creating an environment that is likely to reduce anxiety C) Positioning the client supine D) Encouraging the client to decrease the number of cigarettes smoked daily

Ans: A Feedback: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.

13. A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety B) Nausea C) Pain D) Hypothermia

Ans: A Feedback: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation.

4. A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? A) Fowler's B) Low-Fowler's C) Protective supine D) Semi-Fowler's

Ans: A Feedback: Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.

6. A nurse is conducting a health assessment. How will the information collected from the client be used? A) As a basis for the nursing process B) To illustrate nursing competence C) To facilitate nurse-client caring D) As one component of medical care

Ans: A Feedback: Health assessment is an integral component of nursing care and is the basis of the nursing process. Health assessments by nurses are used to plan, implement, and evaluate education and care. Nursing assessment is different from other types of health care provider assessments, as it is a holistic collection of information about a client's level of health.

3. The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed? A) 45 to 60 degrees B) 15 to 20 degrees C) 30 degrees D) 90 degrees

Ans: A Feedback: In the Fowler's position, the head of the bed is elevated 45 to 60 degrees. Low-Fowler's or semi-Fowler's is positioning of the head of the bed to only 30 degrees. In the high-Fowler's position, the head of the bed is elevated 90 degrees.

3. The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician? A) Decreased heart rate B) Visible pulsation through a thin chest wall C) Sinus dysrhythmia that increases with inspiration and decreases with expiration D) Presence of an S heart sound

Ans: A Feedback: Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound.

19. A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included? A) "Make each breath deep enough to move the bottom ribs." B) "Breathe through the mouth when you inhale and exhale." C) "Breathe in through the mouth and out through the nose." D) "Practice deep breathing at least once each week."

Ans: A Feedback: Instruct the client to make each breath deep enough to move the bottom ribs. Start with deep breaths by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or four times a day.

5. Which of the following diseases may result in decreased lung compliance? A) Emphysema B) Appendicitis C) Acne D) Chronic diarrhea

Ans: A Feedback: Lung compliance refers to the stretchability of the lungs, or the ease with which lungs can be inflated. Emphysema, a chronic lung disease, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which in turn decreases lung compliance.

34. The nurse at the beginning of the shift plans to see which client first, based on the following vital signs? A) The client age 2 years whose respiratory rate is 16 breaths/minute B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC) C) The client age 7 years whose pulse is 120 beats/minute D) The client age 10 years whose blood pressure is 102/62 mmHg

Ans: A Feedback: Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits.

30. During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this? A) Focused assessment B) Spiritual assessment C) Social assessment D) Comprehensive assessment

Ans: A Feedback: Often, nurses must select the most important interviewing questions or assessment techniques to use, and perform a focused health assessment based on the client's problem.

18. A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition? A) Orthostatic hypotension B) Orthostatic hypertension C) Ambulatory bradycardia D) Ambulatory tachycardia

Ans: A Feedback: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.

28. The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of A) Atelectasis B) Bronchospasm C) Croup D) Epiglottitis

Ans: A Feedback: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis.

9. A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication? A) Pneumonia B) Altered thought processes C) Urinary incontinence D) Viral influenza

Ans: A Feedback: The normal changes in the respiratory system associated with aging (such as rigidity of tissues and airways and decreased movement of the diaphragm) coupled with fractured ribs would increase the risk of pneumonia in an older adult.

12. An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? A) Inspiration and expiration B) Only on inspiration C) Only on expiration D) When coughing

Ans: A Feedback: Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors.

21. Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them. A) True B) False

Ans: B Feedback: Antiembolism stockings may be removed (for example, during morning care to inspect the legs) without the primary care provider writing an order to discontinue them.

22. While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? A) Bronchial B) Bronchovesicular C) Vesicular D) Adventitious

Ans: B Feedback: Bronchial breath sounds are high pitched, with expiration longer than inspiration. Bronchovesicular sounds are moderate "blowing" sounds with equal inspiration and expiration. Vesicular sounds are soft and low-pitched, with longer inspiration than expiration. Adventitious sounds are not normally heard in the lungs.

23. A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to two to three quarts per day. C) Maintain bed rest for at least three days. D) Take warm baths every night for a week.

Ans: B Feedback: Clients can keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum the client's health state can tolerate.

19. When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition would the nurse document? A) Jaundice B) Cyanosis C) Erythema D) Pallor

Ans: B Feedback: Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Jaundice is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis. Erythema is redness of the skin associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is paleness of the skin, which often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.

16. Which of the following can a nurse assess by palpation? A) Heart sounds, lung sounds, blood pressure B) Temperature, turgor, moisture C) Vision, hearing, cranial nerves D) Tissue density, gait, reflexes

Ans: B Feedback: Palpation is an assessment technique that uses the sense of touch. The hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.

15. What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? A) "Although the test is uncomfortable, it is not painful." B) "You will be asked to forcefully exhale into a mouthpiece." C) "The test is used to determine how much air you inhale." D) "You will do this each morning while still lying in bed."

Ans: B Feedback: Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma.

10. Which individual is at greater risk for respiratory illnesses from environmental causes? A) A farmer on a large farm B) A factory worker in a large city C) A woman living in a small town D) A child living in a rural area

Ans: B Feedback: Researchers have demonstrated a high correlation between air pollution and lung diseases, including cancer. Air pollution puts people with certain occupations, and those who live in large cities, at a greater risk for these diseases.

27. A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? A) Decreased production of mucus B) Inhibition of mucus removal C) Increase in the mucous escalator D) Inhibition of bacterial colonization

Ans: B Feedback: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.

26. An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Normal pulse

Ans: B Feedback: Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse rate.

31. A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. D) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible.

Ans: B Feedback: The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible.

27. What is one purpose of documentation of the health assessment? A) To identify the nurse's role in health care B) To identify actual and potential health problems C) To expand nursing knowledge and skills D) To provide a basis for evidence-based nursing

Ans: B Feedback: The nurse organizes and documents assessment data to identify actual and potential health problems, to make nursing diagnoses, to plan appropriate care, and to evaluate the client's response to treatment.

26. A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift

Ans: B Feedback: The nurse would turn the client in bed every two hours to avoid complications due to inactivity. The nurse would also include this activity in the client plan of care.

14. A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? A) Anxiety B) Ineffective Airway Clearance C) Excess Fluid Volume D) Disturbed Sensory Perception

Ans: B Feedback: The nursing diagnosis Ineffective Airway Clearance indicates the child is unable to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Although the child is anxious, this is not the priority of care. The other two diagnoses are not supported by the data.

8. A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school."

Ans: B Feedback: The preschool-age child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections increases when the child enters daycare or school and is exposed more frequently to pathogens.

6. Which is the primary source of heat in the body? A) Hormones B) Metabolism C) Blood circulation D) Muscles

Ans: B Feedback: The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise.

13. A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Bigeminal

Ans: B Feedback: The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.

14. A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea? A) "Do you have problems breathing when you walk up stairs?" B) "Does your medication help you breathe better?" C) "How many pillows do you sleep on at night to breathe better?" D) "Tell me about your breathing difficulties since you stopped smoking."

Ans: C Feedback: People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.

7. A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? A) Comprehensive B) Ongoing partial C) Focused D) Emergency

Ans: C Feedback: A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the client about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment. Ongoing partial assessments are conducted at regular intervals, and emergency assessments are carried out in emergency situations (such as prior to CPR).

22. What prevents air from re-entering the pleural space when chest tubes are inserted? A) The location of the tube insertion B) The sutures that hold in the tube C) A closed water-seal drainage system D) Respiratory inspiration and expiration

Ans: C Feedback: After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space.

11. The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings? A) Absent and infrequent B) Shallow and slow C) Rapid and deep D) Noisy and difficult

Ans: C Feedback: Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood tends to increase the rate and depth of respirations. An increase in carbon dioxide is the most powerful respiratory stimulant.

30. A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition? A) Hyperventilation B) Hypoventilation C) Dyspnea D) Apnea

Ans: C Feedback: Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than four to six minutes.

18. A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? A) Supine B) Prone C) High-Fowler's D) Dorsal recumbent

Ans: C Feedback: During inspiration, the diaphragm contracts and descends, lengthening the thoracic cavity. This movement is facilitated by a high-Fowler's position in which the abdominal contents move downward, providing more room for the descent of the diaphragm and greater lung expansion.

16. A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client? A) Thrombophlebitis B) Anemia C) Orthostatic hypotension D) Bradycardia

Ans: C Feedback: Orthostatic hypotension refers to a reduction in blood pressure with position changes from lying to sitting or standing. Blood pooling in the legs increases, thus increasing the postural hypotension. Thrombophlebiits refers to an inflammation of a the veins; it manifests with redness and swelling. Anemia refers to a reduction in hemoglobin. This may present with feelings of weakness. Bradycardia refers to a reduced heart rate.

10. A client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? A) Left ventricle pumps more forcefully; pulse is stronger B) Stimulates the vagus nerve to increase the rate C) Stimulates the vagus nerve to decrease the rate D) Right ventricle is less efficient; pulse is thready

Ans: C Feedback: Parasympathetic stimulation via the vagus nerve decreases the heart rate. The Valsalva maneuver stimulates the vagus nerve, resulting in a slower pulse rate.

16. What does pulse oximetry measure? A) Cardiac output B) Peripheral blood flow C) Arterial oxygen saturation D) Venous oxygen saturation

Ans: C Feedback: Pulse oximetry is a noninvasive technique that measures the oxygen saturation of arterial blood. The normal range is 95% to 100%. It does not measure cardiac output, peripheral blood flow, or venous oxygen saturation.

27. A client in a physician's office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension? A) It depends on the time of day the BP was taken. B) It depends on whether the client is male or female. C) No, a single BP reading should not be used. D) Yes, this reading is high enough to be significant.

Ans: C Feedback: The American Heart Association recommends that blood pressure readings be averaged on two or more subsequent occasions before diagnosing hypertension.

17. Of all factors, what is the most important risk factor in pulmonary disease? A) Air pollution from vehicles B) Dangerous chemicals in the workplace C) Active and passive cigarette smoke D) Loss of the ozone layer of the atmosphere

Ans: C Feedback: The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. Cigarette smoke is the most important risk factor in pulmonary disease.

4. A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? A) Chemoreceptors B) Stretch receptors C) Respiratory center D) Oxygen center

Ans: C Feedback: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies.

15. A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? A) Back of the skull B) Elbows C) Sacrum D) Heels

Ans: C Feedback: The sacrum bears the greatest pressure during a sitting position. The back of the skull, elbows, and heels bear pressure in a supine position.

28. All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned? A) An older adult B) A pregnant adolescent C) A junior high football player D) An infant 2 months of age

Ans: D Feedback: A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms.

15. What population is at greatest risk for hypertension? A) Hispanic B) White C) Asian D) African American

Ans: D Feedback: Race is a factor in hypertension, a disorder characterized by high blood pressure. It is more prevalent and more severe in African American men and women.

23. Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate? A) The radial pulse is more rapid than the apical pulse. B) This is a normal finding and should be ignored. C) The client's arteries are very compliant. D) Not all of the heartbeats are reaching the periphery.

Ans: D Feedback: A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

24. What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? A) Bronchoconstrictors B) Antihistamines C) Narcotics D) Bronchodilators

Ans: D Feedback: A nebulizer is used to adminster medications in the form of an inhaled mist. Bronchodilators are medications that may be administered by nebulizer or metered-dose inhaler to open narrowed airways. Antihistamines are not administered via nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not administered via nebulizer; they are used to manage complaints of pain.

11. A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next? A) Continue with the health history, but more slowly. B) Ask questions of the family instead of the client. C) Conduct the interview later and let the client rest. D) Initiate interventions to help relieve the symptoms.

Ans: D Feedback: Before beginning the interview for a health history, the nurse should ascertain that the client is not in acute distress. If the client is experiencing any respiratory distress, the nurse immediately initiates interventions to help relieve symptoms.

25. While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? A) Air in the lungs B) A narrowing of the upper airway C) Narrowed small air passages D) Moisture in air passages

Ans: D Feedback: Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in small air passages, and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs normally contain air.

17. A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension? A) "Eat a diet high in fruits and vegetables." B) "Remember to drink eight to 10 glasses of water a day." C) "It is important to have increased fats in your diet." D) "Put away the salt shaker and eat low-salt foods."

Ans: D Feedback: High salt intake is a high risk factor for the development of hypertension.

15. A nurse is using inspection as an assessment technique. What does the nurse use during inspection? A) Equipment such as a stethoscope B) Both hands to produce sounds C) Light palpation to detect surfaces D) Senses of vision, hearing, smell

Ans: D Feedback: Inspection is the process of performing deliberate, purposeful observations. The nurse observes visually but also uses hearing and smell to gather data throughout the assessment. A stethoscope is used for auscultation, and the hands are used to percuss and palpate.

20. A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) Using upper chest muscles more effectively B) Replacing the use of incentive spirometry C) Reducing the need for p.r.n. pain medications D) Prolonging expiration to reduce airway resistance

Ans: D Feedback: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance.

22. As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? A) The blood pressure does not change. B) The blood pressure is erratic. C) The blood pressure decreases. D) The blood pressure increases.

Ans: D Feedback: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system. This is reflected in an increased blood pressure.

7. In what age group would a nurse expect to assess the most rapid respiratory rate? A) Older adults B) Middle adults C) Adolescents D) Infants

Ans: D Feedback: The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than any other age group.

35. A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? A) 15 to 25 breaths/minute B) 16 to 20 breaths/minute C) 20 to 44 breaths/minute D) 30 to 55 breaths/minute

Ans: D Feedback: The normal range for an infant's breath per minute is 30 to 60.

35. A nurse walks into a client's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next? A) Take vital signs again in 15 to 30 minutes. B) Document the data and report it later. C) Ask the client if he is anxious or afraid. D) Report findings to the physician immediately.

Ans: D Feedback: The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.

8. What function of the skeletal system is essential to proper function of all other cells and tissues? A) Supporting soft tissues of the body B) Protecting delicate body structures C) Providing storage area for fats D) Producing blood cells

Ans: D Feedback: The production of blood cells (hematopoiesis) is the function of the skeletal system that is essential to all other cells and tissues of the body working properly.

31. A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use? A) Femoral B) Temporal C) Pedal D) Radial

Ans: D Feedback: The radial artery is the site most commonly assessed in a clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior medial aspect of the thigh, just below the inguinal ligament, about halfway between the anterior superior iliac spine and the symphysis pubis. The pulsation of the temporal artery is palpated in front of the upper part of the ear; however, it is not the site most commonly assessed in the clinical setting. The pedal pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the dorsalis pedis pulse may be congenitally absent in some clients.

26. When assessing the abdomen, which assessment technique is used last? A) Inspection B) Auscultation C) Percussion D) Palpation

Ans: D Feedback: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.