HHA Ch 11 & 12

Which is the priority nursing action for a child with severe burns on the arms and who is scheduled for therapeutic escharotomy? A. removing blisters B. monitoring vital signs C. maintaining airborne precautions D. performing passive range-of-motion exercises

B. monitoring vital signs

Which assessment finding reflects increased intracranial pressure (ICP)? A. tachycardia B. unequal pupil size C. decreased body temp D. decreasing systolic BP

B. unequal pupil size

Which clinical manifestation indicates a possible PE in a client after a total hip replacement? A. sudden chest pain B. flushing of the face C. elevation of temp D. abrupt onset of shortness of breath E. hip pain rating increased from 2 to 8

A. sudden chest pain D. abrupt onset of shortness of breath

Which action by the nurse is a priority when a client who is receiving a transfusion of packed RBCs after cardiac surgery experiences chest discomfort, chills, and anxiety? A. administer nitroglycerin B. monitor the clients vital signs C. stop the transfusion and administer normal saline D. ask the client to describe the pain using a 0-10 scale.

C. stop the transfusion and administer normal saline

Which response by the nurse is best when a client who has peripheral arterial disease of the lower extremities tells the nurse "I want so slowly that no one wants to walk with me"? A. many people enjoy walking along B. you will be able to walk faster eventually C. it is important that you keep walking to improve circulation D. perhaps you might consider a supervised exercise training program

D. perhaps you might consider a supervised exercise training program

Which clinical finding would the nurse expect when assessing a client with varicose veins? A. positive homans sign B. pallor of the affected extremity C. prolonged capillary refill in the toes D. sensation of heaviness in lower legs

D. sensation of heaviness in lower legs

The nurse is listening to the patient's heart at the 2nd LSB. Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

4. Pulmonic area

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Measure the thigh circumference to detect an increase from the baseline. 2. Dorsiflex the calf and notice if the patient complains of pain. 3. Elevate one leg above the level of the heart to determine if the veins empty. 4. Palpate the pulses distal to the areas of the suspected thrombosis.

1. Measure the thigh circumference to detect an increase from the baseline.

On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub

1. Rhonchi

Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar

1. Vesicular

Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub

1. Wheeze

The nurse knows that the proper technique for assessing lungs in an adult patient is that auscultation is performed: (SELECT ALL THAT APPLY) 1. from right to left using a "z" pattern. 2. from top to bottom using landmarks for accuracy. using the bell of the 3. stethoscope to hear vascular sounds. 4. to the anterior chest wall and abdomen to determine diaphragm function.

1. from right to left using a "z" pattern.

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). Which measures would the nurse include to increase arterial blood flow to the extremities? 1.Exercises that promote muscular activity 2.Meticulous care of minor skin breakdown 3.Elevation of the legs above the level of the heart 4.Soaking the feet in hot water each day

1.Exercises that promote muscular activity

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

2. "Does the pain go away when you stop walking?"

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2. "What does the pain feel like?"

A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position.

2. Ask the patient to cough then repeat the auscultation.

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. Green 2. Clear 3. Yellow 4. Pink tinged

2. Clear

A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills and difficulty breathing on exertion. Which is an important nursing action? 1. Checking for capillary refill 2. Encouraging increased fluid intake 3. Suctioning secretions from the airway. 4. Administering a high concentration of oxygen.

2. Encouraging increased fluid intake

Where does a nurse palpate the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

2. The inner aspect of the ankle below and slightly behind the medial malleolus

Which of the following promotes perfusion and healing of the surgical wound for an older adult? 1. minimize the use of tape on the skin. 2. keep the client adequately hydrated. 3. change the dressings as soon as they get wet. 4. provide rest for the client throughout the day.

2. keep the client adequately hydrated.

How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. Uses the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae

3. A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? 1. An opening snap 2. A diastolic murmur 3. A systolic murmur 4. A pericardial friction rub

3. A systolic murmur

A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration

3. Decreased breath sounds on auscultation

How does a nurse determine jugular vein pulsations? 1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough

3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion and rhonchi on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe

3. Fever and tachypnea with crackles over the right lower lobe

While inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses

Which finding does the nurse expect during auscultation of the heart? 1. A low-pitched blowing sound is heard over the apex of the heart. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

3. The S1 heart sound is louder at the apex of the heart.

A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? 1. Increased fremitus over the left chest 2. Tracheal deviation to the left side 3. Crepitus on the left chest during palpation 4. Distant to absent breath sounds over the left chest

4. Distant to absent breath sounds over the left chest

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Ms. J, whose blood pressure has been 140/90 2. Mr. Q, whose blood pressure has been 130/76 3. Ms. Y, whose blood pressure has been 120/80 4. Mr. P, whose blood pressure has been 110/78

4. Mr. P, whose blood pressure has been 110/78

During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's race 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate of 20 breaths per minute 4. Patient leaning forward with arms braced on the knees

4. Patient leaning forward with arms braced on the knees

The nurse assesses a patient who has a costal angle greater than 90 degrees. What is the most likely cause of this finding? A. Chronic obstructive pulmonary disease B. Atelectasis C. Pneumothorax D. Pneumonia

A. Chronic obstructive pulmonary disease

Which is a neonatal effect of maternal smoking during pregnancy? A. Low birth weight B. Facial abnormalities C. chronic lung problems D. Hyperglycemic reactions

A. Low birth weight

The nurse percusses a patient's chest and feels dullness. The nurse suspects which diagnosis? A. Pneumonia B. COPD C. Bronchiectasis D. Emphysema

A. Pneumonia

Which assessment item needs to be documented on a client in restraints? Select all that apply A. Pulse near the restrained area B. Temperature of the restrained area C. Convenience of restraining the client D. Skin integrity surrounding the restraint E. Behavior leading to the need for restraint

A. Pulse near the restrained area B. Temperature of the restrained area D. Skin integrity surrounding the restraint E. Behavior leading to the need for restraint

What findings does the nurse expect when auscultating the chest of a healthy adult? (Select all that apply.) A. Symmetric chest B. Expansion muffled voice sounds C. Adventitious sounds and limited chest expansion D. Absent voice sounds and hyperresonant percussion tones E. Increased tactile fremitus and dull percussion tones F. Resonant percussion tones G. Muffled voice sounds and symmetric tactile fremitus

A. Symmetric chest D. Absent voice sounds and hyperresonant percussion tones E. Increased tactile fremitus and dull percussion tones F. Resonant percussion tones

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates A. a normal finding. B. pneumonia. C. lung cancer. D. pleural effusion.

A. a normal finding.

A patient complains to the nurse of coughing up green phlegm and is having difficulty breathing at rest. The nurse suspects A. bacterial pneumonia. B. a viral infection. C. tuberculosis. D. pulmonary edema.

A. bacterial pneumonia.

Which sign or symptoms would the nurse associate with hyperthyroidism? A. fatigue B. dry skin C. anorexia D. bradycardia

A. fatigue

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time? A. helping the client change her position B. informing the client of the problem with the fetus C. administering oxygen by mask to the client at 2L/min D. readjusting placement of fetal monitor on the clients abdomen

A. helping the client change her position

Which finding may indicate post op bleeding to a nurse in the postanesthesia care unit caring for a client who had major abdominal surgery A. oliguria B. bradypnea C. pulse deficit D. hypoglycemia

A. oliguria

Which assessment does the nurse conduct to determine which triage category the client should be assigned to during a mass casualty incident where the nurse is assigned to help triage clients by using sort-assess-life-saving interventions-treatment triage approach (SALT) select all that apply A. perfusion B. cognition C. respiratory system D. musculoskeletal system E. skin of obvious wounds

A. perfusion B. cognition C. respiratory system

A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and chronic peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema should the nurse initially assess? A. Proteinemia B. Contractures C. Tissue ischemia D. Thrombus formation

C. Tissue ischemia

Which finding in a client with pulmonary edema requires the most rapid action but the nurse? A. weak, rapid pulse B. O2 sat of 82% C. BP 99/54 mmHg D. crackles throughout both lungs

B. O2 sat of 82%

Which action will the nurse take first when two hours after a cardiac catheterization that was assessed through the right femoral route, a client reports numbness and pain in the right foot? A. Call the primary health care provider B. Check the clients pedal pulse bilaterally C. Take the clients BP and pulse D. Teach about postcatheterization embolus

B. Check the clients pedal pulse bilaterally

Which priority nursing intervention for a child with severe burns and extensive Escher formation on the arms would the nurse implement? A. Removing blisters B. Checking radial pulses C. Administering pain medication D. Perform range of motion exercises

B. Checking radial pulses

Which action would the nurse implement when an older adult is brought to the emergency department after being found in the street without a coat during a snowstorm? A. Massage extremities B. Obtain rectal temp C. Assess fingers for areas of frostbite D. Determine client's level of consciousness E. Ask for client identification

B. Obtain rectal temp C. Assess fingers for areas of frostbite D. Determine client's level of consciousness E. Ask for client identification

The nurse notes a diaphragmatic excursion of 4 cm on the right side and 8 cm on the left side. What do these findings mean? A. The patient may have a pneumothorax. B. The patient may have a pleural effusion.

B. The patient may have a pleural effusion.

which finding will the nurse expect when caring for a client who is in hypovolemic shock? A. slow heart rate B. cool skin temperature C. bounding radial pulses D. increased urine output

B. cool skin temperature

Which nursing assessment finding indicates dehydration in an infant? A. flat anterior fontanel B. decreased urine output C. warm skin temp D. slow labored respirations

B. decreased urine output

Upon completing a post op assessment, which finding would indicate to the nurse that the client may be experiencing a pulmonary embolus? A. flushed face B. increased temp C. severe abdominal pain D. decreased O2 sat E. sudden onset of shortness of breath

B. increased temp D. decreased O2 sat E. sudden onset of shortness of breath

Which reason would the nurse provide to explain to the client why chemotherapy via regional perfusion is the treatment of choice for a client's malignant sarcoma of the liver this method of medication administration was probably selected? A. Medication therapy can be continued at home with little difficulty B. larger doses of medication's can be delivered to the actual site of the tumor C. toxic effects of the chemotherapeutic medications are confined to the area of the tumor D. combinations of medication's are used to attack neoplastic cells at the various stages of the cell cycle

B. larger doses of medication's can be delivered to the actual site of the tumor

What is the purpose of palpating a patient's chest wall? A. Identification of lung sounds B. Determination of oxygenation C. Assessment of equal chest expansion D. Approximation of lung size

C. Assessment of equal chest expansion

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding? A. Consolidation in alveoli B. Fluid in the alveoli C. Narrowed airways D. Sputum in the bronchi

C. Narrowed airways

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? A. Making huge efforts to avoid "any kind of bug or spider" B. Experiencing flashbacks to an event that involved a sexual attack C. Spending hours each day worrying about something "bad happening" D. Becoming suddenly tachycardic and diaphoretic for no apparent reason

C. Spending hours each day worrying about something "bad happening"

After the nurse educator teaches about post op care of a vascular bypass client, which statement by the new nurse indicated that more education is needed? A. a cool, pale extremity can indicate vascular reocclusion B. hourly assessment of the extremity is needed for the first 24 hours C. a client report of throbbing pain typically indicates vascular reocculsion D. ongoing pain even after the use of the patient-controlled analgesia (PCA) pump indicates possible occlusion

C. a client report of throbbing pain typically indicates vascular reocculsion

Which action would the nurse take when caring for a client on the first postoperative day after a femoral-popliteal bypass graft? A. Keep the client on bed rest B. have the client sit in a chair C. assist the client with ambulation D. position the client with the knees flexed

C. assist the client with ambulation

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? A. urine output 1000mL in 8 hours B. oral temp 101 C. client report of feeling very thirsty D. bounding radial and femoral pulses

C. client report of feeling very thirsty

The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the ____________. A. pectoral muscles B. abdominal muscles C. external intercostal muscles D. scalene muscles

C. external intercostal muscles

Which sign indicates to the nurse that fluid replacement therapy is adequate when assessing a client during the first 24 hours after a burn injury? A. Decreasing central venous pressure (CVP) readings B. hematocrit level increasing from 50% to 55% C. slowing of a previously rapid pulse D. urinary output of 15 to 20 mL/h

C. slowing of a previously rapid pulse

Which client statement provide evidence that the client understands medication teaching for high dose penicillin? A. "I should take this medication with meals" B. "This medication may cause constipation" C. "I must avoid dairy products while taking this medication" D. "I must increase my intake of fluids while taking this medication"

D. "I must increase my intake of fluids while taking this medication"

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What disorder does the nurse suspect? A. Tuberculosis B. Croup C. Pneumonia D. Asthma

D. Asthma

Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed? A. Increasing mobility B. Preventing contractures C. Limit orthostatic hypotension D. Prevent pressure on peripheral blood vessels

D. Prevent pressure on peripheral blood vessels

A client with a fractured head of the right femur is placed in a Buck extension. Which action would the nurse take? A. remove the weights from the traction every 2 hours to promote comfort B. turn the client from side to side every 2 hours to prevent pressure on the coccyx C. raise the knee gatch on the bed every 2 hours to limit the shearing force of traction D. assess the affected leg every 2 hours to ensure adequate tissue perfusion.

D. assess the affected leg every 2 hours to ensure adequate tissue perfusion.

which action will the nurse take first when a client with peripheral arterial disease returns to the nursing unit after a femoral angiogram?A. Check the oral temperature B. Encourage the client to void C. Place the head of the bed flat D. assess the clients affected leg

D. assess the clients affected leg

Which actions by the nurse are priorities in the immediate postoperative period after splenectomy? Select all that apply. One, some, or all responses may be correct. a. monitor heart rate b. take blood pressure c. Listen to bowel sounds d. check urine output e. auscultate lung sounds f. look for abdominal distension

a. monitor heart rate b. take blood pressure d. check urine output e. auscultate lung sounds f. look for abdominal distension

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours? a. To maintain client comfort b. To prevent development of pressure injuries c. To prevent flexion contractures of the extremities d. To improve venous circulation in the lower extremities

b. To prevent development of pressure injuries