NUR 233 EAQ Exam 4 Questions And 100%
Correct Answers
A patient with right ventricular failure asks the nurse to describe this condition. Which of
the following statements should the nurse include in his description?
1
The right ventricle does not pump efficiently, and fluid backs up into the systemic
circulation.
2
There can be enlargement of the liver and spleen.
3
The right ventricle does not pump efficiently, and fluid backs up into the lungs.
4
There is fluid accumulation in the lung and pulmonary edema.
5
There is peripheral edema of the hands and feet. - ANSWER 1, 2, 5
Failure of the right ventricle refers to malfunctioning of the right ventricle of the heart.
Consequently, there is fluid backup in the systemic circulation. This creates pressure on
several organs, hence enlargement of the liver and spleen. There is also swelling of the
fluid in the extremities manifesting as edema. In left ventricular failure, the fluid will back
up into the lungs, hence pulmonary edema.
Which of the following statements is true about chest percussion?
Multiple choice question
Chest percussion utilizes slow tapping to the chest wall.
,Chest percussion is done over a multilayer of clothing.
Chest percussion involves rhythmic clapping on the chest wall.
Chest percussion is frequently given to those who have osteoporosis. - ANSWER Chest
percussion involves rhythmic clapping on the chest wall.
Chest percussion The rhythmic clapping of the chest wall. It is performed by striking
vigorously on the chest wall. It is performed over a single layer of clothing and is
contraindicated in patients who have osteoporosis.
During assessment a patient states, "It's hard for me to breathe and I feel short-winded
all the time." Which is the most appropriate terminology for the nurse to use when
documenting this assessment?
Multiple choice question
Apnea
\bDyspnea
Tachypnea
Respiratory fatigue Dyspnea - ANSWER
Dyspnea The subjective description is reflective of the patient's statement related to
difficulty in breathing. Apnea The state of absence of breathing. Tachypnea It is an
increased rate of breathing, usually greater than 20 breaths per minute. Respiratory
fatigue It is a subjective description. It usually refers to the patient exhibiting signs and
symptoms associated with a comprehensive respiratory assessment. Respiratory
assessment includes: laborious breathing, use of accessory muscles, and slowing of
respirations.
, When evaluating a patient in dyspnea, for what clinical manifestations should the nurse
look?
1
Nasal flaring
2
Increased respiratory rate
3
Decreased respiratory rate
4
Exaggerated respiratory effort
5
Decreased depth of respirations - ANSWER 1,2,4
Dyspnea is a clinical manifestation of hypoxia wherein the patient has labored
breathing. Nasal flaring is noted as the patient attempts to inhale more oxygen.
Increased respiratory rate, respirations become rapid to meet up for the deficiency of
oxygen. Exaggerated respiratory efforts, accessory breathing muscles are used as a
result of increased demand for oxygen. Respiratory rate does not slow down instead it
increases in an effort to meet this increased demand for oxygen. Whereas, here the
depth of respiration is increased instead of decreased, and the respiration becomes
rapid so that the deficiency of oxygen may be compensated.
The nurse is caring for a client who was admitted to the hospital with a diagnosis of
left-sided heart failure. In assessing the patient, which of the following signs and
symptoms would the nurse most likely discover?
1
Dyspnea
2
Fatigue
3
Dizziness
Correct Answers
A patient with right ventricular failure asks the nurse to describe this condition. Which of
the following statements should the nurse include in his description?
1
The right ventricle does not pump efficiently, and fluid backs up into the systemic
circulation.
2
There can be enlargement of the liver and spleen.
3
The right ventricle does not pump efficiently, and fluid backs up into the lungs.
4
There is fluid accumulation in the lung and pulmonary edema.
5
There is peripheral edema of the hands and feet. - ANSWER 1, 2, 5
Failure of the right ventricle refers to malfunctioning of the right ventricle of the heart.
Consequently, there is fluid backup in the systemic circulation. This creates pressure on
several organs, hence enlargement of the liver and spleen. There is also swelling of the
fluid in the extremities manifesting as edema. In left ventricular failure, the fluid will back
up into the lungs, hence pulmonary edema.
Which of the following statements is true about chest percussion?
Multiple choice question
Chest percussion utilizes slow tapping to the chest wall.
,Chest percussion is done over a multilayer of clothing.
Chest percussion involves rhythmic clapping on the chest wall.
Chest percussion is frequently given to those who have osteoporosis. - ANSWER Chest
percussion involves rhythmic clapping on the chest wall.
Chest percussion The rhythmic clapping of the chest wall. It is performed by striking
vigorously on the chest wall. It is performed over a single layer of clothing and is
contraindicated in patients who have osteoporosis.
During assessment a patient states, "It's hard for me to breathe and I feel short-winded
all the time." Which is the most appropriate terminology for the nurse to use when
documenting this assessment?
Multiple choice question
Apnea
\bDyspnea
Tachypnea
Respiratory fatigue Dyspnea - ANSWER
Dyspnea The subjective description is reflective of the patient's statement related to
difficulty in breathing. Apnea The state of absence of breathing. Tachypnea It is an
increased rate of breathing, usually greater than 20 breaths per minute. Respiratory
fatigue It is a subjective description. It usually refers to the patient exhibiting signs and
symptoms associated with a comprehensive respiratory assessment. Respiratory
assessment includes: laborious breathing, use of accessory muscles, and slowing of
respirations.
, When evaluating a patient in dyspnea, for what clinical manifestations should the nurse
look?
1
Nasal flaring
2
Increased respiratory rate
3
Decreased respiratory rate
4
Exaggerated respiratory effort
5
Decreased depth of respirations - ANSWER 1,2,4
Dyspnea is a clinical manifestation of hypoxia wherein the patient has labored
breathing. Nasal flaring is noted as the patient attempts to inhale more oxygen.
Increased respiratory rate, respirations become rapid to meet up for the deficiency of
oxygen. Exaggerated respiratory efforts, accessory breathing muscles are used as a
result of increased demand for oxygen. Respiratory rate does not slow down instead it
increases in an effort to meet this increased demand for oxygen. Whereas, here the
depth of respiration is increased instead of decreased, and the respiration becomes
rapid so that the deficiency of oxygen may be compensated.
The nurse is caring for a client who was admitted to the hospital with a diagnosis of
left-sided heart failure. In assessing the patient, which of the following signs and
symptoms would the nurse most likely discover?
1
Dyspnea
2
Fatigue
3
Dizziness
