Week 2 Lab Quiz

lower extremity pale and cool with decreased pulse

Arterial Problems

A nurse requires a pen light when assessing which areas? (Select all that apply.) a. Pupil reaction b. Middle ear c. Nares of the nose d. Lips e. Pharynx

a, c, e

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? a. Assess the apical pulse for a full minute. b. Assess the apical pulse with a Doppler device. c. Assess the pedal pulses for a full minute. d. Assess the pedal pulses with a Doppler device.

a. Assess the apical pulse for a full minute.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? a. Attach a humidifier bottle to the base of the flow meter. b. Remove the nasal cannula while the client eats. c. Secure the oxygen tubing to the bed sheet near the client's head. d. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

a. Attach a humidifier bottle to the base of the flow meter.

After assessing the client's respiratory system, the nurse listens to his apical pulse. What location is used to listen to his apical pulse? a. Fifth intercostal space at left midclavicular line b. Fifth intercostal space at midsternal line c. Fourth intercostal space midsternal line d. Fourth intercostal space at left scapular line

a. Fifth intercostal space at left midclavicular line

The nurse uses the Rinne test to asses: a. Hearing b. Vision c. Pupil reaction d. Reflexes

a. Hearing

During auscultation of breath sounds on the posterior thorax, the nurse hears high-pitched, fine, short sounds during inspiration. This is most likely what kind of breath sounds? a. Wheezes b. Crackles c. Stridor d. Rhonchi

b. Crackles

The nurse is using a Snellen chart to determine visual acuity. The patient should stand how far away from the chart for an accurate assessment? a. 5 feet b. 10 feet c. 20 feet d. 25 feet

c. 20 feet

Assessment of which body system requires the nurse to auscultate before palpation? a. Head and neck b. Lungs c. Abdomen d. Heart

c. Abdomen

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal? a. Pulse strength 3 b. 1+ pitting edema c. Constricting pupils when directly illuminated d. Hyperactive bowel sounds in all four quadrants

c. Constricting pupils when directly illuminated

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? a. Delivers a constant rate of a specific concentration of oxygen b. Delivers a high concentration of oxygen c. Delivers a low concentration of oxygen d. Restricts the client's ability to eat, speak, or drink

c. Delivers a low concentration of oxygen

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? a. Hypoactive bowel sounds in two quadrants b. Request for a cup of tea and some toast c. Passage of flatus d. Abdominal distention

c. Passage of flatus

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment? a. Uses the bell to listen for lung sounds. b. Uses the diaphragm to listen for bruits. c. Uses the diaphragm to listen for bowel sounds. d. Uses the bell to listen for high-pitched murmurs.

c. Uses the diaphragm to listen for bowel sounds.

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? a. Symmetrical convex sphere shape b. Concave umbilicus c. Bilateral bowel sounds in lower quadrants d. Ecchymosis

d. Ecchymosis

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a. Administer oxygen at 2 L/min. b. Administer prescribed analgesic medication. c. Encourage coughing and deep breathing. d. Raise the head of the bed.

d. Raise the head of the bed.

The primary nurse asks a student nurse to take a new post-op client an incentive spirometer and teach her what it is and how to use it properly. What is the primary goal of incentive spirometer use? a. To measure exhalation force after surgery b. To measure client oxygenation c. To cause the client post-op pain to help waken from anesthesia d. To force deep breaths to keep lungs expanded

d. To force deep breaths to keep lungs expanded

neck vein visible when sitting

Jugular Vein Distention

Nearsightedness

Myopia

ringing in ears

Tinnitus

lower extremity swollen and warm with normal pulse

venous problems