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    Exam Review

    1. The medical-surgical charge nurse is conducting a training workshop for a group of new nurses. Which information would the nurse include in the training as secondary data sources of a client's respiratory system? Select all that apply.
      (SATA)
      A)
      Tuberculin skin test
      B)
      Low socioeconomic status.
      C)
      Complete blood count (CBC)
      D)
      Male gender
      E)
      Aral blood gases (ABG)
      F)
      Chest x-ray
    2. Which respiratory assessment finding will most likely indicate the client is exhibiting asthma?
      A)
      respiratory wheezing
      B)
      normal breath sounds
      C)
      lung sounds clear to auscultation
      D)
      decreased respiratory rate
    3. During an examination of a 57-year old man, you note gynecomastia. Your next best action is what?
      A)
      Request a mammogram.
      B)
      Review the clients medication list for drugs that have gynecomastia as a side effect.
      C)
      Request a breast biopsy.
      D)
      Proceed with the examination, this is a normal part of the aging process.
    4. A client with a diagnosis of pleural inflammation is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear upon auscultation?
      A)
      Wheezes
      B)
      Low pitched, grating rubbing sound
      C)
      Crackles
      D)
      Gurgling
    Page 1 of 6

    Exam Review

    1. The nurse is observing the respiratory effort of a client, and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition(s)? Select All That Apply
      (SATA)
      A)
      Thoracic muscle tenderness
      B)
      Barrel Chest
      C)
      Pectus excavatum
      D)
      Atelectasis
      E)
      Obstruction
    2. The nurse is preparing to auscultate the breath sounds of a client for an asthma exacerbation. Which breath sounds does the nurse anticipate to find upon assessment?
      A)
      High pitch continuous sounds on inspiration and expiration.
      B)
      High pitched short crackling
      C)
      Low pitch continuous rattling on inspiration and expiration.
      D)
      Low pitched grating and rubbing on inhalation and exhalation.
    3. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which assessments should the nurse include for this focused assessment? Select the three options that apply.
      (SATA)
      A)
      Obtaining information about the client's respirations
      B)
      Auscultating lung sounds
      C)
      Assessing the strength of peripheral pulses
      D)
      Obtaining the client's temperature
      E)
      Performing a musculoskeletal and neurological examination
      F)
      Asking the client about a family history of any illness or disease
    4. The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate?
      A)
      The nurse should count the respirations in an unobtrusive manner without informing the client.
      B)
      The nurse should inform the client that they are preparing to count the client's respirations.
      C)
      The nurse should place a hand on the client's chest to count respirations.
      D)
      The nurse should count when the respirations are audible.
    Page 2 of 6

    Exam Review

    1. A nurse in an emergency department (ED) is admitting a client. Select 3 findings in the client's medical record that may be indicative of bronchitis.
      (SATA)
      A)
      temperature
      B)
      complaint of fatigue
      C)
      respiratory assessment
      D)
      use of accessory muscles
      E)
      blood pressure
      F)
      bowel sounds
    2. While ambulating the hall, the client begins to complain of shortness of breath and difficulty breathing. Which term should be documented in the client's medical record?
      A)
      Tachypnea
      B)
      Bradypnea
      C)
      Eupnea
      D)
      Dyspnea
    3. The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?
      A)
      palpable lymph nodes
      B)
      Symmetry.
      C)
      breast sensitivity
      D)
      Tenderness
    4. A client tells the nurse that they are experiencing stabbing pain in the mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of
      A)
      diabetic neuropathy.
      B)
      postherpetic neuralgia.
      C)
      visceral pain.
      D)
      trigeminal neuralgia.
    Page 3 of 6

    Exam Review

    1. Which assessment finding is most likely to be immediately life-threatening?
      A)
      Bronchial breath sounds over a peripheral lung field
      B)
      Soft high-pitched expiratory wheezing with forced expiration.
      C)
      Absent breath sounds over one lung lobe
      D)
      Stridor
    2. You are performing a breast exam on an adult woman. You are inspecting the breasts for signs of retraction. What is the best position to observe for this?
      A)
      Lying supine with arms at the sides.
      B)
      Sitting with the hands pushing into the hips.
      C)
      Lying supine with one arm elevated over her head.
      D)
      Learning forward with hands outstretched.
    3. Which abnormality is depicted in the image below?
      A)
      Scoliosis
      B)
      Lordosis
      C)
      Pigeon Chest
      D)
      Kyphosis
    4. Which abnormality is depicted in the image below?
      A)
      Pectus carinatum
      B)
      Barrel Chest
      C)
      Scoliosis
      D)
      Pectus excavatum
    Page 4 of 6

    Exam Review

    1. The nurse is caring for 4 clients. Which client is at highest risk for skin breakdown?
      A)
      25 year-old with left arm sling
      B)
      72 year-old with incontinence and dementia
      C)
      82 year-old with an ankle fracture
      D)
      45 year-old post total hysterectomy
    2. Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?
      A)
      Atelectasis
      B)
      Pulmonary obstruction
      C)
      Pneumonia
      D)
      Bronchitis
    3. Breast pain that is not associated with the menstrual cycle and has no precipitating factors is documented using which term?
      A)
      Cyclic pain
      B)
      Noncyclic
      C)
      Fibrocystic breast
      D)
      Breast cancer
    4. A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?
      A)
      The client sitting up and leaning over the bedside table,
      B)
      Fine bilateral basilar crackles.
      C)
      A respiratory rate of 9 breaths/min.
      D)
      A large barrel chest.
    Page 5 of 6

    Exam Review

    1. In assessing the lymph nodes of the client's breast, which lymph node will the nurse palpate?
      A)
      Inguinal nodes.
      B)
      Subclavicular nodes.
      C)
      Median lymphatic vessel
      D)
      Ulnar lymphatic vessel
    Page 6 of 6