NURS 204 Final Exam
a loud, course, low pitched sound is heard during a lung assessment. the nurse
recognizes this as which of the following?
a. wheezing
b. stridor
c. rhonchi
d. crackles - correct answerc. rhonchi
a nurse suspects a wound infection after noting what type of drainage?
a. sanguineous
b. serous
c. serosanguineous
d. purulent - correct answerd. purulent
a patient comes into the ED very intoxicated. which of the following reflexes will the
patient exhibit during exam?
a. 0
b. +2
c. +4
d. +1 - correct answer+4 reflexes
a pressure ulcer with full thickness skin loss, but no visible bone, tendon, or muscle
exposed, is classified as:
a. stage 2 pressure ulcer
b. stage 4 pressure ulcer
c. stage 1 pressure ulcer
d. stage 3 pressure ulcer - correct answerd. stage 3 pressure ulcer
a wound fails to heal properly and begins to separate. the nurse documents this as
a. dehiscence
b. granulation tissue
c. evisceration
d. approximation - correct answera. dehiscence
ACTIVITY AND IMMOBILITY
what intervention should the nurse do first when pulling a patient up in bed?
a. obtain a sliding board to reduce friction
b. giving clear commands to the patient
, c. maintain proper body mechanics
d. assess what the patient can do to assist - correct answerd. assess what the patient
can do to assist
administering an IM injection of 2mls. - correct answerinjects 2 ml of air into vial before
draw up
CARDIAC
which of the following occurs during the S1 phase of the cardiac cycle?
a. the mitral and tricuspid valve close
b. the pulmonic and aortic valve close
c. the ventricular pressure falls
d. blood fills the coronary arteries - correct answera. the mitral and tricuspid valve close
correct reason for using the z-track method. - correct answerto keep the medication in
the muscle.
during an assessment, an abdominal heart rate is heard. the nurse needs to perform
which of the following documentation?
a. the nurse will chart by exception
b. a new care plan will be created
c. an incident report will be made
d. past history will be included in notes - correct answera. chart by exception
feeding a patient with dysphagia. - correct answercut food in small pieces
GI/GU
which is the correct order when performing an abdominal assessment?
a. inspection, perc.,palp.,aus
b. insp., palp., perc., as
c. insp., auscultation., perc., palp.
d. perc., palp., auscultation., insp. - correct answerc. inspection, auscultation,
percussion, palpation
HEAD NECK AND NEURO
the nurse is performing a physical exam on her patient. which positions are most used
during a routine physical exam?
a. sitting and supine
b. sitting and knee-chest
a loud, course, low pitched sound is heard during a lung assessment. the nurse
recognizes this as which of the following?
a. wheezing
b. stridor
c. rhonchi
d. crackles - correct answerc. rhonchi
a nurse suspects a wound infection after noting what type of drainage?
a. sanguineous
b. serous
c. serosanguineous
d. purulent - correct answerd. purulent
a patient comes into the ED very intoxicated. which of the following reflexes will the
patient exhibit during exam?
a. 0
b. +2
c. +4
d. +1 - correct answer+4 reflexes
a pressure ulcer with full thickness skin loss, but no visible bone, tendon, or muscle
exposed, is classified as:
a. stage 2 pressure ulcer
b. stage 4 pressure ulcer
c. stage 1 pressure ulcer
d. stage 3 pressure ulcer - correct answerd. stage 3 pressure ulcer
a wound fails to heal properly and begins to separate. the nurse documents this as
a. dehiscence
b. granulation tissue
c. evisceration
d. approximation - correct answera. dehiscence
ACTIVITY AND IMMOBILITY
what intervention should the nurse do first when pulling a patient up in bed?
a. obtain a sliding board to reduce friction
b. giving clear commands to the patient
, c. maintain proper body mechanics
d. assess what the patient can do to assist - correct answerd. assess what the patient
can do to assist
administering an IM injection of 2mls. - correct answerinjects 2 ml of air into vial before
draw up
CARDIAC
which of the following occurs during the S1 phase of the cardiac cycle?
a. the mitral and tricuspid valve close
b. the pulmonic and aortic valve close
c. the ventricular pressure falls
d. blood fills the coronary arteries - correct answera. the mitral and tricuspid valve close
correct reason for using the z-track method. - correct answerto keep the medication in
the muscle.
during an assessment, an abdominal heart rate is heard. the nurse needs to perform
which of the following documentation?
a. the nurse will chart by exception
b. a new care plan will be created
c. an incident report will be made
d. past history will be included in notes - correct answera. chart by exception
feeding a patient with dysphagia. - correct answercut food in small pieces
GI/GU
which is the correct order when performing an abdominal assessment?
a. inspection, perc.,palp.,aus
b. insp., palp., perc., as
c. insp., auscultation., perc., palp.
d. perc., palp., auscultation., insp. - correct answerc. inspection, auscultation,
percussion, palpation
HEAD NECK AND NEURO
the nurse is performing a physical exam on her patient. which positions are most used
during a routine physical exam?
a. sitting and supine
b. sitting and knee-chest
