nur 220 exam 2 practice questions with detailed verified answers

A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. Green 2. Clear 3. Yellow 4. Pink tinged - correct answers 2. Clear During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's race 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate of 20 breaths per minute 4. Patient leaning forward with arms braced on the knees - correct answers 4. Patient leaning forward with arms braced on the knees A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion and rhonchi on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe - correct answers 3. Fever and tachypnea with crackles over the right lower lobe On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub - correct answers 1. Rhonchi A nurse finds the patient's AP diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation 4. Complaint of sharp chest pain on inspiration - correct answers 3. Decreased breath sounds on auscultation How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. Uses the tips of the fingers to palpate the skin over the chest and the alignment of vertebrae 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae - correct answers 4. Uses the palmar surface of fingers of both hands to feel the texture of the skin over the chest and the alignment of vertebrae Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar - correct answers 1. Vesicular Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub - correct answers 1. Wheeze A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position. - correct answers 2. Ask the patient to cough then repeat the auscultation. A nurse in the emergency department is assessing a patient with a moderate left pneumothorax. What does this nurse expect to find during the respiratory examination? 1. Increased fremitus over the left chest 2. Tracheal deviation to the left side 3. Crepitus on the left chest during palpation 4. Distant to absent breath sounds over the left chest - correct answers 4. Distant to absent breath sounds over the left chest The nurse is listening to the patient's heart at the 2nd LSB. Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area - correct answers 4. Pulmonic area A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?" - correct answers 2. "Does the pain go away when you stop walking?" A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? 1. An opening snap 2. A diastolic murmur 3. A systolic murmur 4. A pericardial friction rub - correct answers 3. A systolic murmur When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have shortness of breath?" 4. "Has anyone in your family ever had a similar pain?" - correct answers 2. "What does the pain feel like?" How does a nurse determine jugular vein pulsations? 1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough - correct answers 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle Where does a nurse palpate the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus - correct answers 2. The inner aspect of the ankle below and slightly behind the medial malleolus Which finding does the nurse expect during auscultation of the heart? 1. A low-pitched blowing sound is heard over the apex of the heart. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y." - correct answers 3. The S1 heart sound is louder at the apex of the heart. What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Measure the thigh circumference to detect an increase from the baseline. 2. Dorsiflex the calf and notice if the patient complains of pain. 3. Elevate one leg above the level of the heart to determine if the veins empty. 4. Palpate the pulses distal to the areas of the suspected thrombosis. - correct answers 1. Measure the thigh circumference to detect an increase from the baseline. Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Ms. J, whose blood pressure has been 140/90 2. Mr. Q, whose blood pressure has been 130/76 3. Ms. Y, whose blood pressure has been 120/80 4. Mr. P, whose blood pressure has been 110/78 - correct answers 4. Mr. P, whose blood pressure has been 110/78 While inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses 4. Pain when legs are dependent that is relieved when legs are elevated - correct answers 3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses A patient reports severe abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to gather more data about the possibility of cholelithiasis? 1. "Has your abdomen been distended?" 2. "Have you experienced fever, chills, or sweating?" 3. "Have you vomited up any blood in the last 24 hours?" 4. "Has the color of your urine or stools changed?" - correct answers 4. "Has the color of your urine or stools changed?" The nurse is interviewing a patient with a history of flank pain, fever, and chills. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Palpation of the kidney for contour 4. Auscultation of the lower quadrants of the abdomen - correct answers 1. Percussion of the costovertebral angle A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask as part of a symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Is the pain worse after eating or when your stomach is empty?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?" - correct answers 3. "Is the pain worse after eating or when your stomach is empty?" Which organs is the nurse assessing during palpation of the right upper quadrant of the abdomen? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon - correct answers 1. Liver and gallbladder Using deep palpation of a patient's epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurse's most appropriate response? 1. Auscultate this area using the bell of the stethoscope. 2. Percuss the area for tones. 3. Document this as an expected finding. 4. Ask the patient if there is pain in this area. - correct answers 3. Document this as an expected finding. When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time? 1. Document this as an expected finding for this adult 2. Palpate the upper liver border on deep inspiration 3. Palpate the gallbladder for tenderness 4. Use the hooking technique to palpate the lower border of the liver - correct answers 2. Palpate the upper liver border on deep inspiration Which is an abnormal sound the nurse would detect when auscultating the abdomen using the bell of the stethoscope? 1. High-pitched gurgles 2. Borborygmi 3. Venous hum 4. Absent bowel sounds - correct answers 4. Absent bowel sounds Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Uses the pads of the fingertips to depress the abdomen. - correct answers 4. Uses the pads of the fingertips to depress the abdomen. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? 1. Palpate lightly for tenderness and muscle tone 2. Auscultate for bowel sounds 3. Palpate deeply for masses or aortic pulsation 4. Percuss for tones - correct answers 2. Auscultate for bowel sounds A patient reports having abdominal fullness and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?" - correct answers 3. "What did the vomitus look like?" Which patient's description of pain is consistent with injury to a bone? 1. "Deep, dull, and boring" 2. "Cramping even when not moving" 3. "Intermittent, sharp, and radiating" 4. "Tingling with pins and needles sensation with movement" - correct answers 1. "Deep, dull, and boring" How does the nurse determine if a patient's musculoskeletal examination is normal? 1. By reading the examination findings documented in the patient's chart 2. By comparing findings from other patients in the same age group 3. By reading descriptions in health assessment books 4. By comparing the patient's left side with the right side - correct answers 4. By comparing the patient's left side with the right side While assessing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? 1. Extension of the arm 2. Flexion of the arm 3. Adduction of the arm 4. Abduction of the arm - correct answers 2. Flexion of the arm The nurse assessing the patient's muscle strength finds that the patient has full resistance to opposition. Using Table 14.1, how would this finding be documented? 1. Poor or 2/5 2. Fair or 3/5 3. Good or 4/5 4. Normal or 5/5 - correct answers 4. Normal or 5/5 While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? 1. Flexion, extension, and hyperextension 2. Circumduction, internal rotation, and external rotation 3. Adduction, abduction, and rotation 4. Flexion, pronation, and supination - correct answers 1. Flexion, extension, and hyperextension A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination? 1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally 2. Decreased range of motion of one hip and knee, with pain on flexion and crepitus during movement of these joints 3. Erythema in one great toe, ankle, and lower leg that is painful to the touch 4. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally - correct answers 1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? 1. Passively moves each leg through range of motion and compares the findings 2. Observes the patient's gait and legs as he or she walks across the room 3. Measures the length of each leg and compares the findings 4. Palpates the joints and muscles of each leg and compares the findings - correct answers 3. Measures the length of each leg and compares the findings A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? 1. Inspecting the musculature of the face and neck for symmetry 2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain 3. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side 4. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth - correct answers 2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain When a nurse asks a patient to place the right arm behind the head, the nurse is assessing for which range of motion? 1. Flexion of the elbow 2. Hyperextension of the shoulder 3. Internal rotation and adduction of the shoulder 4. External rotation and abduction of the shoulder - correct answers 4. External rotation and abduction of the shoulder With the patient in a supine position, how does a nurse assess the external rotation of the patient's right hip? 1. Asking the patient to move the right leg laterally with the right knee straight 2. Asking the patient to flex the right knee and turn medially toward the left side (inward) 3. Asking the patient to place the right heel on the left patella 4. Asking the patient to raise the right leg straight up and perpendicular to the body - correct answers 3. Asking the patient to place the right heel on the left patella During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient's ability to swallow? 1. Ask the patient to puff out her cheeks, purse her lips, and blow out. 2. Observe the soft palate when the patient says "ahh." 3. Observe the patient while she swallows water from a paper cup. 4. Wearing gloves, grasp the patient's tongue and palpate all sides. - correct answers 2. Observe the soft palate when the patient says "ahh." As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings does the nurse anticipate during the neurologic exam? 1. When the patient stands with his feet together and eyes closed, his upright posture is maintained. 2. The nurse notices no patient response after striking the right patellar tendon with a reflex hammer. 3. The patient is able to move the heel of one foot down the shin of the other leg while lying supine. 4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand. - correct answers 4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand. During a symptom analysis, the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermatome map (see Fig. 15.8) to determine that the patient's description of pain is consistent with dysfunction of which spinal nerve? 1. Second lumbar (L2) 2. Third lumbar (L3) 3. Fourth lumbar (L4) 4. Fifth lumbar (L5) - correct answers 3. Fourth lumbar (L4) Which question gives the nurse additional information about a patient's report of his hands shaking for the last 2 months? 1. "Does the shaking occur when your hands are at rest or when you are picking up an item?" 2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?" 3. "What actions do you take to relieve the shaking when it occurs?" 4. "Have you ever experienced this shaking before?" - correct answers 1. "Does the shaking occur when your hands are at rest or when you are picking up an item?" Which technique does the nurse use to assess the triceps reflex? 1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon with a reflex hammer 2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer 3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the reflex hammer 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer - correct answers 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? 1. The patient's eyes move to the left, right, up, down, and obliquely. 2. The patient moistens the lips with the tongue. 3. The sides of the mouth are symmetric when the patient smiles. 4. The patient's eyelids blink periodically. - correct answers 3. The sides of the mouth are symmetric when the patient smiles. The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes closed. The nurse then observes the patient moving her foot to maintain balance and opening her eyes. Based on this finding, which additional assessment does th