Exam 3 NUR 2830 / NEWEST STUDY GUIDE COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS

Exam 3 NUR 2830 / NEWEST STUDY GUIDE COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate? a) "If you develop swelling in your ankles or feet, then you should seek emergency care." b) "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD." c) "Quitting smoking and keeping good control of your blood sugar levels are important." d) "It's critical that you come to get screening tests twice annually." - Correct Answer C" "The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development? a) Immobility b) Hypertension c) Smoking d) Obesity - Correct Answer A" A 60-year-old male client presents to the health clinic with a 3-week history of cough, pleuritic chest pain, increasing fatigue, and intermittent fevers. Which data collected in the history should the nurse recognize as risk factors for the development of lung cancer? Select all that apply. a) History of radiation exposure b) Smokeless tobacco c) High-fat diet d) Exposure to asbestos at work e) Moderate alcohol consumption - Correct Answer A D" "The clavicles extend from the acromion of the scapula to the part of the sternum termed the a) body. b) xiphoid process. c) angle. d) manubrium. - Correct Answer D" "During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what? a) Hypertrophic changes b) Venous insufficiency c) Intermittent claudication d) Arterial insufficiency - Correct Answer B" "A client at risk for peripheral arterial disease should be screened by which of the following tests? a) Ankle-brachial index b) Bilateral vascular claudication assessment c) Doppler testing of femoral arteries d) Angiogram of femoral and popliteal arteries - Correct Answer A" "A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client? a) It manufactures T lymphocytes. b) It drains capillary blood from the circulation. c) It filters harmful substances from the body. d) It produces protective antibodies. - Correct Answer C" "The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate? a) "If you develop swelling in your ankles or feet, then you should seek emergency care." b) "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD." c) "Quitting smoking and keeping good control of your blood sugar levels are important." d) "It's critical that you come to get screening tests twice annually." - Correct Answer C" "Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next? a) Perform the Allen test. b) Compare measurements of both extremities. c) Palpate the femoral pulses. d) Check for bilateral varicosities. - Correct Answer C" "A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding? a) History of Raynaud's disorder b) History of breast surgery c) Presence of deep vein thrombosis d) Presence of peripheral artery disease - Correct Answer B" "Choice Multiple question - Select all answer choices that apply. A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply. a) Snoring and gasping while sleeping b) Coughing occurring at night c) Coughing that produces white sputum d) Orthopnea e) Edema f) Angina - Correct Answer D E F" "A client has sustained a brain stem injury and is being treated in the intensive care unit. Which of the following would the nurse need to consider when assessing this client's respiratory status? a) The client will respond negatively to increased stimuli. b) The client will exhibit Cheyne-Stokes respirations. c) The client will have greatly increased respiratory effort. d) The client will have a loss of involuntary respiratory control. - Correct Answer D" "A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings? a) Opiates, which may cause hyperventilation b) Anesthesia, from surgery that morning c) Opiates, which may cause hypoventilation d) Nothing, this is normal following surgery - Correct Answer C" "The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment? a) Begin above the left clavicle and percuss all areas on the left chest, then reverse the process and assess the right chest moving upward from the liver. b) Begin at the sternal notch and percuss all areas on the right chest then all areas on the left chest. c) Begin above the right clavicle and percuss each section comparing the right chest with the left chest. d) Begin at the sternal notch and percuss all areas on the left chest then all areas on the right chest. - Correct Answer C" "While auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration and long expiration. The nurse would document this as which of the following? a) Adventitious breath sounds b) Vesicular breath sounds c) Bronchovesicular breath sounds d) Bronchial breath sounds - Correct Answer D" "A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is a) exercise-induced asthma b) a foreign body obstruction c) increased secretions d) a severe cold - Correct Answer B" "How should a nurse position a client to accurately auscultate the right middle lobe of the lung? a) Lateral with the right lung facing up b) Rest the arms on the knees c) Move the right arm away from the body d) Lean forward at the waist - Correct Answer C" "A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? a) The time from firing of the sinoatrial (SA)node to the beginning of depolarization in the ventricle b) The spread of depolarization and sodium release in the ventricles to cause ventricular contraction c) The spread of depolarization in the atria d) Relaxation of the ventricles and repolarization of the cells - Correct Answer A" "Choice Multiple question - Select all answer choices that apply. "Choice Multiple question - Select all answer choices that apply. The nurse is preparing to conduct a physical examination of a patient's cardiovascular system. What should the nurse instruct the patient in preparation for this examination? (Select all that apply.) a) Explain that gloves will be worn during the examination. b) A sheet will be draped over the patient for comfort. c) Wear the gown with the opening in the front. d) The patient will be standing during the examination. e) The nurse will be conducting the examination from the left side. - Correct Answer A B C E" "What is located at the right and left 2nd intercostal spaces next to the sternum? a) Pulmonary vein b) Aortic valve c) Apex of the heart d) Base of the heart - Correct Answer D" "While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is a) a wheezing sound. b) heard when the artery is almost totally occluded. c) a normal sound heard in adult clients. d) associated with occlusive arterial disease. - Correct Answer D" "Lung tissue has no pain fibers. a) False b) True - Correct Answer B" "The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's a) pectus diaphragm. b) pectus excavatum. c) pectus carinatum. d) pectus thorax. - Correct Answer B" "The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible a) chronic bronchitis. b) atelectasis. c) congestive heart failure. d) renal failure. - Correct Answer A" "A client presents to the health care facility with a two (2) week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a one (1) pack per day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data? a) Disturbed Sleep Pattern b) Impaired Gas Exchange c) Ineffective Airway Clearance d) Risk for Imbalanced Nutrition Submit your answer - Correct Answer B" "The nurse auscultates the base of the lungs to assess for what reason? a) It best reflects the health of the lungs. b) It indicates fluid that has accumulated inside of the lungs. c) It is where fluid occurs with with pulmonary edema. d) It indicates early infection. - Correct Answer C" "The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs? a) Bronchovesicular b) Vesicular c) Bronchial d) Tracheal - Correct Answer B" "The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis? a) Sudden onset of dyspnea b) History of heart failure c) Relief of dyspnea with guided deep breathing d) Fine crackles to bases on auscultation - Correct Answer A" "The thin double-layered serous membrane that lines the chest cavity is termed a) parietal pleura. b) pulmonary pleura. c) thoracic pleura. d) visceral pleura. - Correct Answer A" "The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates a) diabetic ketoacidosis. b) congestive heart failure. c) drug overdose. d) central nervous system injury. - Correct Answer A" "The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem? a) Heart failure b) Myocardial infarction c) Peripheral arterial disease (PAD) d) Venous thromboembolism - Correct Answer A" "While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area? a) Edema b) Shortness of breath c) Palpitations d) Chest pain - Correct Answer B" "A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? a) Isometric contraction b) Ventricular contraction c) Closure of the atrioventricular (AV) valves d) Closure of the semilunar valves - Correct Answer D" "A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data? a) Ineffective Tissue Perfusion b) Ineffective Health Maintenance c) Activity Intolerance d) Impaired Breathing Pattern - Correct Answer A" "During auscultation of the heart, a nurse hears an extra heart sound immediately after S2 at the second left intercostal space. What should the nurse do to further assess this finding? a) Watch the client's respirations while listening for effect on the heart sound b) Observe the jugular vein for distention at 30, 60, and 90 degrees of head elevation c) Ask the client to lean forward to bring the left ventricle closer to the chest wall d) Ask the client about previous history of cardiac problems such as heart failure - Correct Answer A" "The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal? a) 2 b) 4 c) 6 d) 8 - Correct Answer C" "A nurse is having trouble finding the apical pulse on an obese person. What is the most likely reason for this? a) Poorer conduction of electrical impulses in the heart due to fatty tissue b) Increased difficulty in locating the heart c) Weaker ventricles due to low compliance d) Increased distance from the apex of the heart to the pre cordium - Correct Answer D" "A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur? a) Grade 5 b) Grade 2 c) Grade 6 d) Grade 1 - Correct Answer A" "A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nause and diaphoresis. The nurse should prepare for which treatment? a) Open heart surgery b) Balloon angioplasty c) Morphine and observation d) Nitroglycerin with no restrictions on activity - Correct Answer B" "The nurse on the cardiac unit is caring for a patient who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this patient, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein? a) They more than double the risk of cardiac disease. b) They are clinical proof that the patient had a coronary event. c) They have no direct correlation with increased risk of cardiac disease. d) They are both sensitive and specific to heart failure. - Correct Answer A" "To function adequately, the nurse knows that the heart valves need to open simultaneously. a) True b) False Submit your answer - Correct Answer B" "A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia? a) Premature atrial contractions b) Premature ventricular contractions c) Atrial fibrillation d) Sinus arrhythmia - Correct Answer D" "A nurse is working with an older client who has decreased left ventricular compliance. The nurse understands that this condition will cause a decrease in the amount of blood pumped from the heart with each contraction, a measure known as which of the following? a) Stroke volume b) Systolic blood pressure c) Cardiac output d) Heart rate - Correct Answer A" "A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate understanding of the waveforms when they identify which component as indicating ventricular repolarization? a) P wave b) ST segment c) T wave d) QRS complex - Correct Answer C" "A nurse experiences difficulty differentiating S1 from S2 when auscultating a client's heart sounds. What is an appropriate action by the nurse? a) Turn the client to the left side b) Ask the client to hold the breath c) Palpate the carotid pulse simultaneously d) Listen with the bell of the stethoscope - Correct Answer C" "The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action? a) Increase intravenous fluid rate. b) Encourage increased PO fluid intake. c) Place the client in supine position. d) Administer prescribed diuretic. - Correct Answer D" "After teaching a group of students about the traditional areas of auscultation of heart sounds, the instructor determines that the teaching was successful when the students identify which of the following as Erb's point? a) Third to fifth intercostal space at the left sternal border b) Fifth intercostal space near the left midclavicular line c) Second or third intercostal space at the left sternal border d) Second intercostal space at the right sternal border - Correct Answer A" "The nursing instructor explains to a group of students that what can shorten diastole? a) Increased heart rate b) Blood pressure c) Filling pressures d) Decreased respirations - Correct Answer A" "A nurse experiences difficulty with palpation of the apical impulse on the pre cordium. What is an appropriate action by the nurse? a) Use the stethoscope to auscultate b) Instruct the client to cough and attempt again c) Ask the client to assume the left lateral position d) Try using one finger of the dominant hand to locate the pulse - Correct Answer C" "By what percent can clients reduce their risk of cardiac events the first year after quitting smoking? a) 30% b) 40% c) 50% d) 60% - Correct Answer C" "A nurse suspects that a client may have a pericardial friction rub. To ensure that the nurse hears this, the nurse would place the client in which position? a) Supine with head of bed elevated 30 degrees b) Leaning forward while in a sitting position c) Sitting upright in a straight back chair d) Flat, left lateral - Correct Answer B" "Which of the following conditions would produce a hyperresonant percussion note? a) Lobar pneumonia b) Pleural effusion c) Empyema d) Large pneumothorax - Correct Answer D" "When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi? a) Suprasternal notch b) Sternal angle c) Midaxillary line d) T4 spinous process - Correct Answer D" "When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse? a) The lung has become airless b) The lung is overinflated c) The lung is full of fluid d) The lung has an embolus - Correct Answer A" "While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing a) thrombophlebitis. b) varicose veins. c) arterial insufficiency. d) venous stasis. - Correct Answer C" "After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded? a) iliofemoral b) communicating c) popliteal d) saphenous - Correct Answer C" "A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client's circulation is normal and free of arterial occlusion? a) 0.8 b) 0.5 c) 1.1 d) 1.4 - Correct Answer C" "A nurse inspects the lower extremities of a client and notices that the legs appear asymmetrical. What should the nurse do first in regards to this finding? a) Measure the diameter of the calves. b) Assess for the presence of pitting edema. c) Palpate for temperature in the feet. d) Notify the health care provider. - Correct Answer A" "Choice Multiple question - Select all answer choices that apply. The nurse is going to assess a patient's ankle-brachial index. Which equipment will the nurse use for this assessment? (Select all that apply.) a) Reflex hammer b) Blood pressure cuff c) Tape measure d) Doppler device e) Stethoscope - Correct Answer B D" "A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Have the client stand upright after tourniquet removal b) Tourniquet should be put on before leg elevation c) Ensure that the client's legs are over the side of the bed d) Legs should be elevated for 15 seconds - Correct Answer D" "When reviewing the adult circulation, the nurse understands that which mechanism primarily aids in returning blood to the heart?? a) Pressure gradients b) Muscular contractions c) Gravitational flow d) Heart muscle contraction - Correct Answer B" "A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next? a) Lightly palpate the client's leg veins for tenderness b) Use a Doppler ultrasound device on the client's leg c) Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe d) Have the client sit down - Correct Answer A" "The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients? a) Femoral b) Radial c) Ulnar d) Brachial - Correct Answer C" "A nurse performs the Allen test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test? a) Ensure that the client's hand is not opened in exaggerated extension b) Have the client rest the hand palm side up and make a fist c) Use the thumbs to occlude the radial and ulnar arteries d) Keep both arteries occluded and have the client release the fist - Correct Answer A" "The nurse is assessing a patient with Raynaud disease. When assessing the wrist pulses, what would the nurse expect to find? a) Bounding wrist pulses b) Absent wrist pulses c) Normal wrist pulses d) Decreased wrist pulses - Correct Answer C" "The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely? a) Trauma b) Arterial insufficiency c) Neuropathic ulcer d) Venous insufficiency Submit your answer - Correct Answer D" "A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding? a) Lower arm and hand for erythema and swelling b) Abdomen, noting any organ enlargement or tenderness c) Cervical lymph nodes for tenderness and swelling d) Head and neck for recent ear infection or sore throat - Correct Answer B" "A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what? a) Contraction of the ventricles b) Relaxation of the ventricles c) Closure of the aortic and pulmonic valves d) Closure of the mitral and tricuspid valves - Correct Answer D" "Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration. a) Tracheal b) Bronchovesicular c) Bronchial d) Vesicular - Correct Answer C" "A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding? a) Atelectasis has occurred b) Decreasing intensity is normal at the base c) Client needs to speak louder d) An area of consolidation is present - Correct Answer B" "Which vessels return the lymph fluid to circulation? a) Thoracic ducts b) Internal jugular ducts c) Epitrochlear ducts d) Infraclavicular ducts - Correct Answer A" "Choice Multiple question - Select all answer choices that apply. The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.) a) inspecting the hands and lower legs b) inspecting and palpating the precordium c) auscultating the lungs d) examining the face e) examining the neck - Correct Answer A B D E" "A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur? a) Upright b) Upright, but leaning forward c) Supine d) Left lateral decubitus - Correct Answer B"