Nurs 225 Quiz 2 Practice Qs

When the nurse is assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? a) Aching pain in the left calf b) Burning pain in the left calf c) Numbness and tingling in the left leg d) Coldness of the left foot and ankle

d) Coldness of the left foot and ankle

The patient with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do? a) Avoid walking when the pain occurs b) Rest frequently with the legs elevated c) Wear support stockings d) Enroll in a supervised exercise training program

d) Enroll in a supervised exercise training program

A 25 year old woman presents in the Emergency Department with acute abdominal pain in her right lower quadrant. This is the woman's first time in the hospital. The nurse should first assess her: a) Abdomen b) Respiratory status c) Circulation d) Pain

d) Pain

Which of the following is important to remember when providing passive range of motion exercises for your patient? a) Allow the patient to move his/her extremities independently b) Ask the patient to contract their muscles c) The patient will experience pain during movement of each joint d) Slowly provide the movements of each joint for the patient

d) Slowly provide the movements of each joint for the patient Rationale: passive ROM is when the nurse moves the client's joints. Active ROM is when the patient moves on their own

TRUE OR FALSE: Hearing a bruit when auscultating one of the abdominal arteries is considered a normal assessment finding for the abdomen.

False

Which of the following characteristics should be noted when assessing the presence of a murmur? SATA. a) Amplitude b) Location c) Loudness d) Pattern e) Pitch f) Quality

b) Location c) Loudness d) Pattern e) Pitch f) Quality Rationale: amplitude is the force of a palpable pulse

The nurse is assessing the lower extremities of the client with peripheral artery disease. Which findings are expected? SATA. a) Hairy legs b) Mottled skin c) Pink skin d) Coolness e) Moist skin

b) Mottled skin d) Coolness

You are to get a patient with right-sided weakness up into a chair. On which side of the bed will you place the chair? a) Either side, because you are assisting the patient b) On the patient's left side c) On the patient's weak side d) On whichever side the patient prefers

b) On the patient's left side Rationale: always place an assistive device on the patient's strong side

When performing a nursing assessment, which assessment technique should the nurse begin after inspecting the abdomen? a) Auscultation b) Olfaction c) Palpation d) Percussion

a) Auscultation Rationale: always auscultate the abdomen before palpating

To maintain proper posture, it is important to a) Avoid arching shoulders forward sitting b) Keep your knees locked when standing upright c) Keep your stomach muscles relaxed to prevent back spasms d) Sleep on the softest mattress possible

a) Avoid arching shoulders forward sitting

You ask your patient to abduct his right leg. Which of the following demonstrates the proper action? a) Moves his leg away from his body b) Moves his leg closer towards his body c) Raises his leg up off the bed d) Straightens his leg

a) Moves his leg away from his body

When assessing the amplitude (force) of a peripheral pulse site, which of the following grading would be considered normal? a) +1 b) +2 c) +3 d) +4

b) +2

You are caring for a patient who had an indwelling catheter removed 12 hours ago. The patient has not voided. What action should you take? a) Ask the patient why he or she hasn't voided yet b) Assess the patient's bladder and recent intake & output c) Call the physician immediately d) Do nothing as the catheter was only removed 12 hours ago

b) Assess the patient's bladder and recent intake & output Rationale: First, the nurse should assess the patient. How much fluid has the patient had to drink? Does the patient have other output, such as vomiting or drainage? What has the usual output been? After an indwelling catheter is removed, the patient has 6 hours to void. Notify the physical on after fully assessing the patient's situation first.

The nurse is assessing a patient with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues? a) Blood pressure of 102/64 mm Hg b) Cool pale extremities c) Heart rate of 104 BPM d) Shortness of breath when supine

b) Cool pale extremities

A client with heart failure has bilateral +4 edema of the right ankle that extends up to the midcalf. The client is sitting in a chair in no evident distress with legs in a dependent position. What should the nurse do first? a) Assist the client to bed b) Request a prescription for support stockings c) Elevate the clients legs on a foot stool d) Take the clients blood pressure

c) Elevate the clients legs on a foot stool

The nurse knows that the primary reason for the application of a sequential compression device (SCD) on the legs of an immobile patient is to: a) Aid in the peripheral circulation to minimize the risk of skin breakdown b) Assist in passive range of motion exercise in the patient's lower extremities c) Help prevent the formation of deep vein thrombosis (DVT) d) Stimulate circulation in the deep arterial or vascular system

c) Help prevent the formation of deep vein thrombosis (DVT)

You are able to assess the abdomen of a patient who has been experiencing diarrhea for the past two days. Which of the following assessment findings would you expect for this patient? a) Absent bowel sounds b) Hypoactive bowel sounds c) Hyperactive bowel sounds d) Normal bowel sounds

c) Hyperactive bowel sounds

As you make patient rounds, you discover a collection bag for an indwelling catheter placed on the bed above the level of the patient's bladder. What should you do first? a) Assess the patient's bladder by palpating the bladder b) Ask the patient if he or she is in pain c) Lower the collection bag to properly drain the bladder d) Readjust and re-secure the leg strap to the catheter

c) Lower the collection bag to properly drain the bladder Rationale: First, lower the bag and drain the bladder. Then you will also want to determine how long the bag has been like this and assess the patient.

A nurse hears an irregular heart rate of 110 bpm when listening to the patient's chest. After assessing the patient and noting new onset of shortness of breath, which action should the nurse do next? a) Check the availability of medication to relieve anxiety b) Recheck the pulse later in the shift c) Obtain a prescription for a stat echocardiogram d) Call the radiology service to obtain a stat chest x-ray

c) Obtain a prescription for a stat echocardiogram

Where does the electrical conduction/electrical firing of the heart begin? a) AV node b) Bundle branches c) SA node d) Purkinje fibers

c) SA node Electrical conduction in the heart: SA node --> AV node --> bundle of His --> bundle branches --> Purkinje fibers

One goal is caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal? a) Avoid eating low fat foods b) Elevate the legs above the heart c) Stop smoking d) Jog daily

c) Stop smoking Rationale: cigarette smoking causes coronary vasoconstriction, an increase in coronary vascular resistance, and a decrease in coronary blood flow, despite an increase in myocardial oxygen demand

Which of the following is true when auscultating the abdomen for bowel sounds? a) Bowel sounds should be heard every 1 to 2 seconds b) Bowel sounds are absent if not heard within 1 minute c) The nurse should auscultate the abdomen for bowel sounds in all 4 quadrants for 1 minute d) The nurse should auscultate the abdomen for bowel sounds by using the bell of the stethoscope

c) The nurse should auscultate the abdomen for bowel sounds in all 4 quadrants for 1 minute

The nurse is unable to palpate the client's left pedal pulse. What should the nurse do first? a) Auscultate the pulses with a stethoscope b) Call the health care provider (HCP) c) Use a Doppler ultrasound device d) Inspect the lower left extremity

c) Use a Doppler ultrasound device