While performing a patient's skin assessment, the nurse observes erythema. What may
have caused this finding? Select all that apply.
A. Fever
B. Shock
C. Suntan
D. Blushing
,E. Direct trauma
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A. Fever
D. Blushing
E. Direct trauma
The nurse is performing a physical examination on a patient. Where should the nurse
palpate for the apical impulse?
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Fifth intercostal space at the midclavicular line.
Rationale:
The apex of the heart touches the fourth to fifth intercostal space just
medial to the left midclavicular line; the apical impulse is palpated best in
this anatomical region.
While measuring the degree of pitting edema in a patient, the nurse documents 2+.
What is the depth of this?
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4 mm
, A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min. While in the supine position for a bath, the patient complains of shortness of
breath. Which is the most appropriate first nursing action?
A. Increase the flow of oxygen.
B. Perform tracheal suctioning.
C. Report this to the healthcare provider.
D. Assist the patient to semi-Fowler's position.
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D. Assist the patient to semi-Fowler's position.
Rationale:
LEAST invasive first; Manipulate position/environment first
The nurse is examining the thorax and lungs. Which technique used by the nurse
would be beneficial for listening to the lung sounds?
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Auscultation
A patient comes to a clinic for a regular checkup. The nurse is performing a physical
examination of the patient. Which interventions should the nurse follow during
inspection to get the best results? Select all that apply.
Give this one a try later!
have caused this finding? Select all that apply.
A. Fever
B. Shock
C. Suntan
D. Blushing
,E. Direct trauma
Give this one a try later!
A. Fever
D. Blushing
E. Direct trauma
The nurse is performing a physical examination on a patient. Where should the nurse
palpate for the apical impulse?
Give this one a try later!
Fifth intercostal space at the midclavicular line.
Rationale:
The apex of the heart touches the fourth to fifth intercostal space just
medial to the left midclavicular line; the apical impulse is palpated best in
this anatomical region.
While measuring the degree of pitting edema in a patient, the nurse documents 2+.
What is the depth of this?
Give this one a try later!
4 mm
, A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2
L/min. While in the supine position for a bath, the patient complains of shortness of
breath. Which is the most appropriate first nursing action?
A. Increase the flow of oxygen.
B. Perform tracheal suctioning.
C. Report this to the healthcare provider.
D. Assist the patient to semi-Fowler's position.
Give this one a try later!
D. Assist the patient to semi-Fowler's position.
Rationale:
LEAST invasive first; Manipulate position/environment first
The nurse is examining the thorax and lungs. Which technique used by the nurse
would be beneficial for listening to the lung sounds?
Give this one a try later!
Auscultation
A patient comes to a clinic for a regular checkup. The nurse is performing a physical
examination of the patient. Which interventions should the nurse follow during
inspection to get the best results? Select all that apply.
Give this one a try later!
