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Final Exam: NURS120/ NURS 120 (Latest 2024/ 2025 Update) Introduction to Medical Surgical Nursing | Qs & As| Grade A| 100% Correct (Verified Answers)- WCU

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Course NURS120/ NURS 120 (NURS120)
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Final Exam: NURS120/ NURS 120 (Latest 2024/ 2025 Update) Introduction to Medical Surgical Nursing | Qs & As| Grade A| 100% Correct (Verified Answers)- WCU Q: The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally. Answer: d. Auscultate anterior and posterior breath sounds bilaterally. To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. Q: The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration Answer: c. Discontinuous, high-pitched sounds of short duration heard on inspiration Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high- pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration. Q: The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. I will use my inhaler right before the test. b. I wont eat or drink anything 8 hours before the test. c. I should inhale deeply and blow out as hard as I can during the test. d. My blood pressure and pulse will be checked every 15 minutes after the test. Answer: c. I should inhale deeply and blow out as hard as I can during the test. For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. Q: The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth. Answer: c. The student places the stethoscope over the posterior chest and listens during inspiration. Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences. Q: The patient has sickle cell crisis and is being discharged what should you instruct them? Answer: H.O.P Hydration Q: What are adverse reactions of receiving blood? Answer: - low back pain - chills - tachycardia Q: What would a patient with ulcerative collitis have anemia? Answer: chronic blood loss causes anemia Q: What are possible risk factors for pernicious anemia? Answer: - gastric bypass - alcoholism - PPI long term use Q: What are symptoms of angina? Answer: - diaphoresis - fatigue - dizziness - tachycardia - abdominal issue NO HEADACHE NO ORTHOPNEA Q: What patient education should the nurse provide about the medication Captopril?

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FinallExam:lNURS120/lNURSl120l(Latestl
Update)lIntroductionltolMedicallSurgical
lNursingl|lQsl&lAs|lGradelA|l100%lCorrectl
(VerifiedlAnswers)-lWCU

Q:lThelnurselpalpateslthelposteriorlchestlwhilelthelpatientlsaysl99landlnoteslabsentlfremitus.l
Whichlactionlshouldlthelnurseltakelnext?

a.lPalpatelthelanteriorlchestlandlobservelforlbarrellchest.
b.lEncouragelthelpatientltolturn,lcough,landldeeplbreathe.
c.lReviewlthelchestlx-raylreportlforlevidenceloflpneumonia.l
d.lAuscultatelanteriorlandlposteriorlbreathlsoundslbilaterally.


Answer:
d.lAuscultatelanteriorlandlposteriorlbreathlsoundslbilaterally.

Tolassesslforltactilelfremitus,lthelnurselshouldluselthelpalmsloflthelhandsltolassesslforlvibration
lwhenlthelpatientlrepeatslalwordlorlphraselsuchlasl99.lAfterlnotinglabsentlfremitus,lthelnurselsh
ouldlthenlauscultatelthellungsltolassesslforlthelpresencelorlabsenceloflbreathlsounds.lAbsentlfre
mituslmaylbelnotedlwithlpneumothoraxlorlatelectasis.




Q:lThelnurselcompleteslalshiftlassessmentlonlalpatientladmittedlinlthelearlylphaseloflheartlfail
ure.lWhenlauscultatinglthelpatientsllungs,lwhichlfindinglwouldlthelnurselmostllikelylhear?

a.lContinuouslrumbling,lsnoring,lorlrattlinglsoundslmainlylonlexpiration
b.lContinuouslhigh-pitchedlmusicallsoundslonlinspirationlandlexpiration
c.lDiscontinuous,lhigh-pitchedlsoundsloflshortldurationlheardlonlinspiration
d.lAlserieslofllong-duration,ldiscontinuous,llow-pitchedlsoundslduringlinspiration


Answer:
c.lDiscontinuous,lhigh-pitchedlsoundsloflshortldurationlheardlonlinspiration

,Finelcrackleslarellikelyltolbelheardlinlthelearlylphaseloflheartlfailure.lFinelcrackleslareldisconti
nuous,lhigh-
lpitchedlsoundsloflshortldurationlheardlonlinspiration.lRhonchilarelcontinuouslrumbling,lsnorin
g,lorlrattlinglsoundslmainlylonlexpiration.lCourselcrackleslarelalserieslofllong-
duration,ldiscontinuous,llow-pitchedlsoundslduringlinspiration.lWheezeslarelcontinuouslhigh-
pitchedlmusicallsoundslonlinspirationlandlexpiration.




Q:lThelnurselteacheslalpatientlaboutlpulmonarylfunctionltestingl(PFT).lWhichlstatement,liflm
adelbylthelpatient,lindicateslteachinglwasleffective?

a.lIlwillluselmylinhalerlrightlbeforeltheltest.
b.lIlwontleatlorldrinklanythingl8lhourslbeforeltheltest.
c.lIlshouldlinhaleldeeplylandlblowloutlaslhardlaslIlcanlduringltheltest.
d.lMylbloodlpressurelandlpulselwilllbelcheckedleveryl15lminuteslafterltheltest.


Answer:
c.lIlshouldlinhaleldeeplylandlblowloutlaslhardlaslIlcanlduringltheltest.

ForlPFT,lthelpatientlshouldlinhaleldeeplylandlexhalelasllong,lhard,landlfastlaslpossible.lTheloth
erlactionslarelnotlneededlwithlPFT.lTheladministrationloflinhaledlbronchodilatorslshouldlbelavo
idedl6lhourslbeforelthelprocedure.




Q:lThelnurselobserveslalstudentlwholisllisteningltolalpatientsllungslwholislhavinglnolproblem
slwithlbreathing.lWhichlactionlbylthelstudentlindicateslalneedltolreviewlrespiratorylassessmentl
skills?

a.lThelstudentlstartslatlthelapicesloflthellungslandlmovesltolthelbases.
b.lThelstudentlcompareslbreathlsoundslfromlsideltolsidelavoidinglbonylareas.
c.lThelstudentlplaceslthelstethoscopeloverlthelposteriorlchestlandllistenslduringlinspiration.
d.lThelstudentlinstructslthelpatientltolbreathelslowlylandlallittlelmoreldeeplylthanlnormallthroug
hlthelmouth.


Answer:
c.lThelstudentlplaceslthelstethoscopeloverlthelposteriorlchestlandllistenslduringlinspiration.

,Listeninglonlylduringlinspirationlindicateslthelstudentlneedslalreviewloflrespiratorylassessmentl
skills.lAtleachlplacementloflthelstethoscope,llistenltolatlleastlonelcycleloflinspirationlandlexpira
tion.lDuringlchestlauscultation,linstructlthelpatientltolbreathelslowlylandlallittleldeeperlthanlnor
mallthroughlthelmouth.lAuscultationlshouldlproceedlfromlthellunglapicesltolthelbases,lcompari
ngloppositelareasloflthelchest,lunlesslthelpatientlislinlrespiratoryldistresslorlwillltireleasily.lIflso
,lstartlatlthelbasesl(seelFig.l26-
7).lPlacelthelstethoscopeloverllungltissue,lnotloverlbonylprominences.




Q:lThelpatientlhaslsicklelcelllcrisislandlislbeingldischargedlwhatlshouldlyoulinstructlthem?

Answer:
H.O.P

Hydration




Q:lWhatlareladverselreactionsloflreceivinglblood?

Answer:
-llowlbacklpain
-lchills
-ltachycardia




Q:lWhatlwouldlalpatientlwithlulcerativelcollitislhavelanemia?

Answer:
chroniclbloodllosslcauseslanemia




Q:lWhatlarelpossiblelrisklfactorslforlperniciouslanemia?

, Answer:
-lgastriclbypass
-lalcoholism
-lPPIllongltermluse




Q:lWhatlarelsymptomsloflangina?

Answer:
-ldiaphoresis
-lfatigue
-ldizziness
-ltachycardial
-labdominallissue

NOlHEADACHE
NOlORTHOPNEA




Q:lWhatlpatientleducationlshouldlthelnurselprovidelaboutlthelmedicationlCaptopril?

Answer:
Avoidlsaltlsubstitutes




Q:lWhatlisltheluselofllisinopril?

Answer:
antihypertensivel
-ldecreaseslBP




Q:lWhatldoeslthelabsenceloflthelPlwavelindicate?

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