03 Feb asthma Question 10 When

Question 1 The nurse is performing an assessment on an adult. The adult’s vital signs are normal and the capillary refill time is 5 seconds. What should the nurse do next? Ask the patient about a past history of frostbite. Suspect that the patient has a venous insufficiency problem. Consider this a delayed capillary refill time and investigate further. Consider this a normal capillary refill time that requires no further assessment. Question 2 During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: Lymphadema Raynauds disease Venous thrombosis Chronic arterial insufficiency Question 3 During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: tactile fremitus crepitus friction rub adventitious sounds Question 4 The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. Top to bottom. Side to side. Posterior to anterior. Interspace by interspace. Question 5 The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? To measure the rate of lymphatic discharge. To evaluate the adequacy of capillary patency before venous blood draws. To evaluate the adequacy of collateral circulation before cannulating an artery. To assess the rate of a radial pulse. Question 6 The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: atelectactic crackles and are not pathological. fine crackles, possibly a sign of pneumonia. vesicular breath sounds. course crackles. Question 7 The nurse knows that normal splitting of the second heard sound is associated with: inspiration expiration exercise state low resting heart rate Question 8 The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. Voice sounds are muffled, faint and almost inaudible when the patient whispers “one, two, three” in a soft voice. As the patient says “ninety-nine” repeatedly, the examiner hears “ninety-nine” clearly. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distiguish what is said. As the patient says a long “ee-ee-ee” sound the examiner also hears a long “ee-ee-ee” sound. As the patient says a long “ee-ee-ee” sound the examiner hears a long “aaaaaa” sound. Question 9 During auscultation of the lungs of an adult patient, the nurse notices the prescence of bronchophony. The nurse should assess for signs of which condition? airway obstruction emphysema pulmonary consolidation asthma Question 10 When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: Sounds normally auscultated over the trachea. Bronchial breath sounds are are normally heard in that location. Vesicular breath sounds and are normally heard in that location. Bronchovesicular breath sounds and are normally heard in that location. Question 11 When listening to heart sounds, the nurse knows that S1: Is louder than S2 at the base of the heart. Indicates the beginning of diastole. Coincides with the carotid artery pulse. Is caused by the closure of the semilunar valves. Question 12 In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: Palpate the artery in the upper one third of the neck. Listen with the bell of the stethoscope to assess for bruits. Palpate both arteries simultaneously to compare amplitude. Instruct the patient to take slow deep breaths during auscultation. Question 13 When performing a respiratory assessment on a patient, the nurse notices a costal angle of less than 90 degrees. This is a characteristic of: seen in patients with kyphosis. indicative of pectus excavatum. a normal finding in a healthy adult. an unexpected finding in a patient with a barrel chest. Question 14 A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. venous obstruction claudication due to venous abnormalities ischemia caused by a partial blockage of the arterial supply ischemia caused by a complete blockage of the arterial supply Question 15 When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: mitral and tricuspid tricuspid and aortic aortic and pulmonic mitral and pulmonic Question 16 During a cardiovascular assessment, the nurse knows that an S4 hear sound is: heard at onset of the artrial diastole Usually a normal finding in the elderly heard at the end of ventricular diastoles heard best over the left second intercostal space with the individual sitting upright. Question 17 A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? thin, shiny atrophic skin a unilaterally cool foot pallor of the toes and cyanosis of the nail beds a brown discoloration to the skin of the lower leg

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