NUR 220A Final Exam Multiple Choices Questions With 100% Verified Answers

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area - correct answers 4 which age group has the following fine motor skills: follows with eyes to midline, hands predominantly closed, strong grasp reflex - correct answers 1 month old 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 Which device is most appropriate for preventing foot drop in a patient on bed rest? a. splint b. trapeze bar c. transfer belt d. antiembolism hose - correct answers a Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath - correct answers 3 which age group has the following gross motor skills: turns head to side, keeps knees tucked under abdomen when pulled to sitting position, has gross head lag and rounded, swayed back - correct answers 1 month old 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 episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?" - correct answers 2 Which mineral supplement is most likely to be included in the medication list for a patient with osteoporosis? a. zinc b. calcium c. sodium d. iron - correct answers b which age group has the following fine motor skills: grasps rattle, plays with hands together, inspect hands, carries object to mouth - correct answers 4 month old How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of 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; looks for jugular vein pulsations during the cough - correct answers 3 Where does a nurse palpate to assess 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 extension tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus - correct answers 2 Which condition is most commonly associated with damage to the lower spinal cord? a. hemiparesis b. paraplegia c. quadriplegia d. hemiplegia - correct answers b On auscultation of the heart, the nurse recognizes which expected finding? 1. A low-pitched blowing sound is heard over the abdominal aorta. 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 which age group has the following fine motor skills: can reach and pick up object, may play with toes - correct answers 5 month old What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 244 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline. - correct answers 4 The nurse fits elastic stockings on a patient following major abdominal surgery. The nurse explains to the patient that the stockings help prevent which condition? a. varicose veins b. muscular atrophy c. joint contractures d. deep vein thrombosis - correct answers d 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. Mr. P, whose blood pressure has been 110/78 2. Ms. J, whose blood pressure has been 140/90 3. Mr. Q, whose blood pressure has been 130/76 4. Ms. Y, whose blood pressure has been 120/80 - correct answers 1 which age group has the following fine motor skills: holds spoon or rattle, drops object and reaches for 2nd offered object, holds bottle - correct answers 6 month old Which activities are examples of anaerobic exercise? Select all that apply. a. walking b. heavy weight lifting c. squat jumps d. fast stair climbing e. moderate swimming - correct answers b, c, d While inspecting the legs of a male patient, the nurse notes 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 pulses 4. Pain when legs are dependent that is relieved when legs are elevated - correct answers 3 A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? 1. the furosemide is causing dehydration 2. cloudy urine may be indicative of infection 3. the client has inadequate urine output 4. all of the indications are within normal findings - correct answers 2 which age group has the following fine motor skills: beginning thumb-finger grasping, releases object at will, grasps for toys out of reach - correct answers 8 month old Which risk is associated with estrogen therapy in a client who smokes? 1. hypcalcemia 2. vaginal bleeding 3. multiple pregnancies 4. thromboembolic disorders - correct answers 4 Which conditions are diagnosed more frequently in infancy and childhood than in adulthood? Select all that apply. a. spina bifida b. osteoporosis c. osteoarthritis d. cerebral palsy e. rheumatoid arthritis - correct answers a, d A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis - correct answers 3 which age group has the following fine motor skills: may hold cup and spoon and feed self fairly well with practice, can offer toys and release them, releases cube in cup - correct answers 12 month old Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1. once the tablet is dissolved, spit out the saliva 2. take tablets 3 minutes apart up to a maximum of five tablets 3. common side effects include headache and low blood pressure 4. once opened, the tablets should be refrigerated to prevent deterioration - correct answers 3 A nurse is using the Braden Scale. Which characteristic about a patient is the nurse assessing? a. perception of pain b. fall risk c. risk for skin breakdown d. risk of venous thrombosis - correct answers c A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1. lips 2. sclera 3. conjunctiva 4. mucus membrane - correct answers 1 Which device should the nurse use to reduce the risk of external hip rotation in a patient recovering from hip surgery? a. quad cane b. trapeze bar c. trochanter roll d. ankle foot orthotic (AFO) splint - correct answers c A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1. atrial fibrillation 2. sinus tachycardia 3. ventricular fibrillation 4. first-degree ventricular block - correct answers 2 which age group has the following fine motor skills: can put raisins into bottle, take off shoes and pulls toys, builds tower of 2 cubes, scribbles, uses cup well but rotates spoon - correct answers 15 month old When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include? 1. ambulating the client 2 hours after the procedure 2. checking the vital signs every 15 minutes for 8 hours 3. keeping the client nothing by mouth for 4 hours after the procedure 4. maintaining the supine position for a minimum of 4 hours - correct answers 4 which age group has the following fine motor skills: builds tower of 3-4 cubes, turns pages in book 2-3 at a time, manages spoon without rotating - correct answers 18 month old What is the minimum heart rate of a 14 year old? Record your answer using a whole number. _____________ beats per minute - correct answers 60 bpm Which body system controls balance? a. musculoskeletal b. nervous c. pulmonary d. cardiovascular - correct answers b A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1. increases the cardiac workload 2. interferes with usual respirations 3. produces an elevation in temperature 4. decreases the amount of oxygen - correct answers 1 which age group has the following fine motor skills: able to turn doorknob, able to take off shoes and socks, able to build 7-8 block tower, dumps raisins from bottle following demonstration - correct answers 24 month old (2 years) Which measurement is appropriate in determining the correct length of a cane for a patient? a. the floor to the hip joint b. the floor to the elbow c. the shoulder to the hip joint d. the great toe to the lesser trochanter - correct answers a A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. elevate the foot of the bed 2. perform urinary catheter care every 12 hours 3. place in the high-fowler position 4. perform a neurovascular assessment every 2 hours - correct answers 4 The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client should be instructed to do during the test? 1. keep a diary of activities 2. stay away from microwave ovens 3. avoid taking any nitroglycerin that day 4. take both blood pressure and pulse every 2 hours - correct answers 1 which age group has the following fine motor skills: able to build 8 block tower, scribbling techniques continue, feeds self with increased neatness, dumps raisins from bottle spontaneously - correct answers 30 month old (2 1/2 years) A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. alignment of legs on x-ray 2. warmth of the toes of both feet 3. mobility of the knees when flexed 4. presence of posterior tibial pulses - correct answers 2 Which assessment finding does the nurse expect to observe in a child with cerebral palsy? a. spasticity b. paraplegia c. quadriplegia d. osteoarthritis - correct answers a The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? 1. calling the primary healthcare provider 2. changing the maternal position 3. obtaining the maternal blood pressure 4. preparing the environment for an immediate birth - correct answers 2 which age group has the following gross motor skills: actively lifts head up and looks around, rolls from prone to supine, no head lag when pulled to sitting position, when pulled into sitting position, shows only slight head lag - correct answers 4 month old The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? 1. increased appetite 2. clubbing of the nail beds 3. hypertension 4. weight gain - correct answers 4 which findings characterize contracture? a. muscle wasting b. altered awareness of posture and movement c. permanent fixation of a joint d. spontaneous bone break without trauma - correct answers c A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1. acidosis 2. cardiac arrest 3. psychotic like reactions 4. edema of the extremities - correct answers 2 which age group has the following gross motor skills: able to push up from prone and maintain weight on forearms, rolls from prone to supine, remains straight back when sitting - correct answers 5 month old A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1. to prevent dyspnea 2. to prevent cyanosis 3. to increase oxygen concentration to heart cells 4. to increase oxygen tension in the circulating blood - correct answers 3 Which body mechanics principles should the nurse adopt to prevent injury at work? Select all that apply. a. bend at the knees b. pull rather than push patients or objects c. keep the spine in natural alignment while lifting or transferring d. get assistance when moving patients e. keep the weight to be lifted as close to the body as possible - correct answers a, c, d, e Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. relax in a reclining position 2. sit upright with legs extended 3. walk around at least every hour 4. sit in any position that relieves pressure on the legs - correct answers 3 which age group has the following gross motor skills: begins to raise abdomen off of table, sits but still shaky posture, may sit with legs apart, holds arms straight between legs, supports almost full body weight when pulled to standing - correct answers 6 month old A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? 1. warning the client about the possibility of fluid overload 2. monitoring the clients response, particularly within the first 10 minutes 3. adjusting the clients transfusion flow rate so that it infuses a consistent rate during the procedure 4. having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion - correct answers 2 Which nursing interventions promote lung expansion in an immobile patient? Select all that apply. a. range of motion exercises b. routine coughing c. kegel exercises d. incentive spirometry e. deep breathing exercises - correct answers b, d, e The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? 1. prolong the course of labor 2. cause decreased placental perfusion 3. lead to transient episodes of hypertension 4. interfere with free movement of the coccyx - correct answers 2 which age group has the following gross motor skills: sits securely without support, bears weight on legs when supported, may stand holding on - correct answers 8 month old To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1. they help the venous blood return to the heart 2. they will not cause discomfort, but gently massage the legs 3. they are used instead of anticoagulant therapy 4. they must be worn until the first time the client gets out of bed - correct answers 1 which structure connects muscle to bone? a. tendon b. cartilage c. ligament d. contracture - correct answers a A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1. trimming toenails so that they are short and rounded 2. checking bathwater temperature by putting the toes in first 3. using alcohol to rub hands, feet, legs, and arms at least two times a day 4. seeking professional treatment for any injuries to the extremities - correct answers 4 which age group has the following gross motor skills: able to twist and turn and maintain posture, able to sit from standing position, may stand alone - at least momentarily - correct answers 12 month old Which heart sound is normally heard in a toddler that is considered abnormal in an adult over 30-years-old? - correct answers S3 Which action supports proper body mechanics when lifting or carrying objects? a. keeping the knees in a locked position b. bending at the waist c. elevating work surfaces to elbow height d. holding objects away from the body - correct answers c Which complications does the nurse anticipate in the client who has blue-colored nail beds? - correct answers cardiopulmonary disease which age group has the following gross motor skills: walks alone well, able to seat self in chair, creeps upstairs, cannot throw ball without falling - correct answers 15 month old A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? - correct answers Quality of respirations and presence of pulses Which assessment finding is most commonly observed in patients who have suffered strokes? a. spasticity b. hemiplegia c. paraplegia d. quadriplegia - correct answers b A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take? - correct answers Place the client in the supine position and take the vital signs which age group has the following gross motor skills: may walk up and down stairs holding hand, may show running ability - correct answers 18 month old A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? - correct answers Assess for dizziness. After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? a. allow the area to be exposed to air until all drainage has stopped b. place several cold packs over the area, protecting the skin around the wound c. cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration d. cover the area with sterile guaze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly - correct answers c Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? - correct answers Yellow which age group has the following gross motor skills: may walk up stairs by self, step 2 ft each step, able to walk backward, able to kick ball - correct answers 24 month old (2 years) A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure? - correct answers Reduces the circulating blood volume A nurse administers an analgesic medication to a patient with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? a. before the administration b. 90 minutes after administration c. immediately after administration d. 30 minutes after administration - correct answers d A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? - correct answers The client may have atrial fibrillation. which age group has the following gross motor skills: able to jump from object, walking becomes more stable; wide-based gait decreases, throws ball overhanded - correct answers 30 month old (2 1/2 years) A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? - correct answers Verify the pulse by using a Doppler. Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound? a. raising the bed height to a higher level b. elevating the patient's leg for 30 minutes c. ensuring the bandage is clean and rolled d. exposing the wound for some time before wrapping it - correct answers b The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area - correct answers 4 range of motion: thumb moving thumb across palmar surface of hand - correct answers flexion 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 Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain? a. I b. II c. III d. IV - correct answers a 3. Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath - correct answers 3 range of motion: thumb moving thumb straight away from hand - correct answers extension The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation? a. explain the procedure to the patient b. notify the primary health care provider c. apply the bandage to the patient immediately d. elevate the patient's leg for 15 minutes before applying the bandage - correct answers a 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 episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?" - correct answers 2 How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of 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; looks for jugular vein pulsations during the cough - correct answers 3 The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply. a. a malnourished patient b. an obese patient c. a young adult d. a female patient e. a patient with wound infection - correct answers a, b, e Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table. - correct answers 1 range of motion: thumb extending thumb laterally - correct answers abduction A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding at this age. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician. - correct answers 1 range of motion: thumb move thumb back to normal position - correct answers adduction While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures - correct answers 3 The nurse is making rounds with the primary health care provider, who prescribes cold therapy. Which adaptation is the effect of cold therapy? a. vasodilation b. decreased pain c. wound debridement d. decreased joint stiffness - correct answers b range of motion: thumb touch thumb to each finger of the same hand - correct answers opposition What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Small tears will be noted when their newborn cries. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close. - correct answers 4 An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? 1. Faces Pain Scale 2. Pediatric Symptom Checklist (PSC) 3. Guidelines for Adolescent Prevention (GAP) 4. Oucher Scales - correct answers 3 The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing would be applied? a. granulation b. primary intention c. tertiary intention d. secondary intention - correct answers b Which are expected findings of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in the peripheral lung fields - correct answers 4 range of motion: hip moving leg forward and up - correct answers flexion Which finding of a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration - correct answers 2 The nurse is caring for a patient who has undergone ankle surgery. The primary health care provider places a Jackson-Pratt device in the patient. Which nursing action by the nurse indicates a need for further teaching? a. recompresses the device after emptying b. wears gloves while emptying the reservoir c. uses a medication cup to collect the drainage d. places the container above the level of the wound - correct answers d What would be an abnormal finding for a 7-year-old African American boy? 1. Abdominal distention 2. Umbilical hernia 3. Abdominal breathing 4. Tenseness of abdominal muscles - correct answers 1 range of motion: hip moving leg back beside other leg - correct answers extension When examining the genitalia of a 3-year-old boy, which position is ideal? 1. Prone position with legs flexed in a frog leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed - correct answers 4 what factor increases the risk of wound infection? a. absence of necrotic tissue b. absence of foreign body in wound c. reduced local tissue defenses