NURS 347 Final Exam (week 9-16)
Questions and Correct Answers
While performing an admission assessment for a client, the nurse notes that the client
has varicose veins with ulcerations and lower extremity edema with a report of a feeling
of heaviness. Which of the following nursing diagnoses should the nurse identify as
being the priority in the client's care? ✅impaired tissue perfusion
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that
the documentation states that the radial pulses are "1+." The nurse recognizes that this
reading indicates what type of pulse? ✅weak
A patient complains of leg pain that wakes him at night. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing: ✅problems related to arterial insufficiency
A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe? ✅Brownish discoloration to the skin of the lower leg
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: ✅Raynaud's phenomenon
S.E. is a 30 year old Caucasian male with no significant past medical history and family
history is unremarkable. He had a recent basketball injury resulting in a torn Achilles
tendon 3 weeks ago and a non-weight bearing cast was placed. He is complaining of
right calf pain. Which of the following is indicative of deep vein thrombosis? ✅Right calf
slightly red & swollen a few cm larger than the left calf with all pulses equal bilaterally
When performing a peripheral vascular assessment on a patient, the nurse is unable to
palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal.
Next, the nurse should: ✅Consider this finding as normal, & proceed with the
peripheral vascular evaluation
When performing an assessment of a patient, the nurse notices the presence of an
enlarged right epitrochlear lymph node. What should the nurse do next? ✅Examine the
patient's lower arm & hand, & check for the presence of infection or lesions
, The nurse is reviewing the risk factors for venous disease. Which of these situations
best describes a person at highest risk for the development of venous disease?
✅Person who has even on bed rest for 4 days
The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-
hip ratios. Which one of these patients would be at increased risk? ✅29-year-old
woman whose waist measures 33 inches and hips measure 36 inches
The nurse is percussing the seventh right intercostal space at the midclavicular line over
the liver. Which sound should the nurse expect to hear? ✅Dullness
The nurse is assessing the forms of support an older patient has before she is
discharged. Which of these examples is an informal source of support? ✅Patient's
neighbor, who visits with her daily
A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She
has had adequate intake of calories and appears well nourished. After further
assessment, what would the nurse expect to find? ✅Decreased serum albumin
During reporting, the student nurse hears that a patient has hepatomegaly and
recognizes that this term refers to: ✅enlarged liver
The nurse is assessing a patient for possible peptic ulcer disease. Which condition or
history often causes this problem? ✅frequent use of nonsteroidal antiinflammatory
drugs
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of
tenderness in the left upper quadrant with deep palpation. Which of these structures is
most likely to be involved? ✅spleen
The nurse knows that during an abdominal assessment, deep palpation is used to
determine: ✅enlarged organs
Which of these percussion findings would the nurse expect to find in a patient with a
large amount of ascites? ✅dullness across the abdomen
The nurse is preparing to examine a patient who has been complaining of right lower
quadrant pain. Which technique is correct during the assessment? ✅examine the
tender area last
The nurse has palpated a lump in a female patient's right breast. The nurse documents
this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is
nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no
axillary lymphadenopathy are observed. What information is missing from the
documentation? ✅size of the lump
Questions and Correct Answers
While performing an admission assessment for a client, the nurse notes that the client
has varicose veins with ulcerations and lower extremity edema with a report of a feeling
of heaviness. Which of the following nursing diagnoses should the nurse identify as
being the priority in the client's care? ✅impaired tissue perfusion
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that
the documentation states that the radial pulses are "1+." The nurse recognizes that this
reading indicates what type of pulse? ✅weak
A patient complains of leg pain that wakes him at night. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing: ✅problems related to arterial insufficiency
A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe? ✅Brownish discoloration to the skin of the lower leg
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: ✅Raynaud's phenomenon
S.E. is a 30 year old Caucasian male with no significant past medical history and family
history is unremarkable. He had a recent basketball injury resulting in a torn Achilles
tendon 3 weeks ago and a non-weight bearing cast was placed. He is complaining of
right calf pain. Which of the following is indicative of deep vein thrombosis? ✅Right calf
slightly red & swollen a few cm larger than the left calf with all pulses equal bilaterally
When performing a peripheral vascular assessment on a patient, the nurse is unable to
palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal.
Next, the nurse should: ✅Consider this finding as normal, & proceed with the
peripheral vascular evaluation
When performing an assessment of a patient, the nurse notices the presence of an
enlarged right epitrochlear lymph node. What should the nurse do next? ✅Examine the
patient's lower arm & hand, & check for the presence of infection or lesions
, The nurse is reviewing the risk factors for venous disease. Which of these situations
best describes a person at highest risk for the development of venous disease?
✅Person who has even on bed rest for 4 days
The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-
hip ratios. Which one of these patients would be at increased risk? ✅29-year-old
woman whose waist measures 33 inches and hips measure 36 inches
The nurse is percussing the seventh right intercostal space at the midclavicular line over
the liver. Which sound should the nurse expect to hear? ✅Dullness
The nurse is assessing the forms of support an older patient has before she is
discharged. Which of these examples is an informal source of support? ✅Patient's
neighbor, who visits with her daily
A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She
has had adequate intake of calories and appears well nourished. After further
assessment, what would the nurse expect to find? ✅Decreased serum albumin
During reporting, the student nurse hears that a patient has hepatomegaly and
recognizes that this term refers to: ✅enlarged liver
The nurse is assessing a patient for possible peptic ulcer disease. Which condition or
history often causes this problem? ✅frequent use of nonsteroidal antiinflammatory
drugs
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of
tenderness in the left upper quadrant with deep palpation. Which of these structures is
most likely to be involved? ✅spleen
The nurse knows that during an abdominal assessment, deep palpation is used to
determine: ✅enlarged organs
Which of these percussion findings would the nurse expect to find in a patient with a
large amount of ascites? ✅dullness across the abdomen
The nurse is preparing to examine a patient who has been complaining of right lower
quadrant pain. Which technique is correct during the assessment? ✅examine the
tender area last
The nurse has palpated a lump in a female patient's right breast. The nurse documents
this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is
nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no
axillary lymphadenopathy are observed. What information is missing from the
documentation? ✅size of the lump
