Exam Review
- A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?A)Inspection of the shape and configuration of the chest during normal breathingB)Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10C)Percussion of the posterior chest to initiate vibration of the lung structuresD)Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine’’
- A nurse is auscultating the lungs of a sleeping client and hears short, popping, crackling breath sounds that stop after a few breaths. How should the nurse document these breath sounds in the client's medical record?A)Atelectatic crackles that do not have a pathologic causeB)Fine crackles that may be a sign of impending pneumoniaC)Vesicular breath soundsD)Fine wheezes
- A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?A)The best time to perform BSE is immediately prior to the menstrual cycleB)If pregnancy is suspected, BSE should not be performed until post deliveryC)The best time to perform BSE is 4 to 7 days after the first day of the menstrual periodD)The woman with diagnosed fibrocystic breast tissue should not rely on BSE
- A nurse is listening to the heart sounds of a client. What information about S2 sounds should the nurse recognize as accurate?A)S2 indicates the beginning of diastoleB)S2 coincides with the carotid artery pulseC)S2 is caused by the closure of the semilunar valvesD)S2 is louder than an S1
Exam Review
- A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?A)When the client is obeseB)When part of the lung is obstructed or collapsedC)When accessory muscles are used to facilitate respiratory effortD)When bulging of the intercostal spaces is present
- A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?A)DysphagiaB)RhinitisC)XerostomiaD)Epistaxis
- A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?A)Listening for sounds from the apex to the heart to the base of the heart.B)Listening to the sounds at the site where the apical pulse is heard to be the loudest.C)Listening from the base of the heart across and down, then over to the apex.D)Listening to the sounds at the aortic, tricuspid, pulmonic, arid mitral areas.
- A nurse is assessing the symmetry of a client's chest. The nurse should understand that which technique best confirms symmetric expansion of the chest?A)Inspection of the shape and configuration of the chest wall during normal breathingB)Placing hands sideways posterolateral chest wall with thumbs pointing together at the level of T9 or T10C)Percussion of the posterior chest to initiate vibration of the lung structuresD)Placing the palmar surface of the fingers of one hand against the chest having the client repeat "ninety-nine"
Exam Review
- A nurse reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?A)The atria contract toward the end of diastole and push the remaining blood into the ventriclesB)Contraction the atria at the beginning of diastole can be felt as a clickC)The ventricles contract during systole and attempt to push against closed atriaD)Atrial kick is the pressure exerted against the atria as the ventricles contract during systole
- A nurse is reviewing the sequence of the cardiac cycle. The nurse recognizes that the electrical stimulus of the cardiac cycle follows which sequence?A)AV node-• SA node-• bundle of His -• Erb's PointB)Bundle of His -• AV node -• SA node -• Erb's PointC)AV node -• SA node -• bundle of His -• bundle branchesD)SA node -• AV node -• bundle of His -• bundle branches
- A nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from these findings?A)Tactile fremitusB)Adventitious soundsC)Friction rubD)Crepitus
- A nurse s teaching a group of clients about modifiable risk factors for cardiovascular disease. Which of the following should the nurse include in the teaching? (Select All that Apply).A)High cholesterolB)DiabetesC)AgeD)WeightE)Smoking
Exam Review
- A client was recently diagnosed with a heart murmur and is asking the nurse for more information. How should the nurse describe to the client about what a heart murmur is?A)A heart murmur is a high-pitched sound caused by a narrowing of a heart valveB)A heart murmur is an extra sound heard from blood entering a rigid heart chamberC)A heart murmur is a sound generated by inflammation around the heart muscleD)A heart murmur indicates turbulent blood flow through a valve in the heart
- A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?A)Obtain a throat culture for possible streptococcal (strep) infectionB)Continue with the assessment, looking for any other abnormal findingsC)Refer the client to their primary providerD)No response is needed; this appearance is normal for the tonsils
- A nurse is auscultating breath sounds of a client with pneumonia. The nurse should recognize that lung consolidation produces which adventitious sound?A)Bronchial soundsB)CracklesC)Whispered pectoriloquyD)Bronchophony
- A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. The nurse should recognize that which of the following is the correct response to these findings?A)Obtain a threat culture for possible streptococcal (strep) infectionB)Continue with the assessment, looking for any other abnormal findingsC)Refer the client to their primary providerD)No response is needed, this appearance is normal for the tonsils
Exam Review
- A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?A)Palpate the chest symmetricallyB)Ask the client to coughC)Use the bell of the stethoscopeD)instruct the client to breathe deeply
- A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)A)Client's oral temperature is 38.40 C (101.2° F).B)Client reports the rash on their back is itchy.C)Client reports nausea following, administration of pain medication.D)Client has a vesicular rash on their upper back.E)Client reports dull, aching pain in lower right call.
- A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner should indicate that further instruction is needed?A)The partner places the client's arm above the level of the client's heartB)The partner centres the cuff bladder over the client's brachial arteryC)The partner wraps the blood pressure cuff around the client's using firm pressureD)The partner checks the instrument gauge to ensure the reading starts at zero
- A nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?A)Use the Snellen chart positioned 20 feet away from the clientB)Determine the client’s ability to read newsprint at a distance of 12 to 14 inchesC)Perform the confrontation testD)Ask the client to read the print on a handheld jaeger card
Exam Review
- A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?A)The eye focuses the image in the center of the pupilB)Constriction both pupils occurs in response to bright lightC)The eye focuses the light on the scleraD)Dilation of both pupils occurs in response to bright light
- A nurse is teaching a client about internal structures of the breast. The should understand that the internal breast consists what structures?A)A blend of fibrous, glandular, and adipose tissuesB)Primarily milk ducts which function a milk reservoirsC)Primarily muscle with small amounts of fibrous tissueD)Glandular tissue to attach the breast to the chest wall
- A nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?A)The third heart sound (S3)B)The fourth heart sound (S4)C)A split-second heart sound S2D)A friction nub
- A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?A)Lid lag when moving the eyes from a superior to an inferior positionB)Nystagmus when reading the Snellen chartC)Parallel movement of both eyesD)Convergence of the eyes