NSG 3600 Unit 2 Quizzes Questions and answers

NSG 3600 Unit 2 Quizzes Questions and answers A client suffering from chronic obstructive pulmonary disease complains that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to: Increase her fluid intake to thin secretions The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal? Fine crackles to the bases of the lungs bilaterally The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of? Crackles Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? Wheezes During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? Flowmeter You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize? Nonrebreather mask A nurse is assessing the lungs of a patient and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? Document normal breath sounds. A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development? Braden Scale The nurse is conducting an assessment of a 74-year-old patient's integumentary system. Which of the following findings should the nurse document as an anomaly that may warrant follow-up? The patient states that a mole on his forehead has become larger in recent months. A nurse performing an integumentary inspection on a client gently pinches the skin under the clavicle. This nurse is assessing: skin turgor You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately? A sterile, flexible applicator moistened with saline Which of the following types of wound drainage should alert the nurse to the possibility of infection? Foul-smelling drainage that is grayish in color A weak, thready pulse found after the nurse palpates peripheral pulses may indicate which condition? Decreased cardiac output Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse. The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? Inspect the left lower leg for areas of redness. Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism The nurse at the neighborhood family clinic is instructing a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client? "Take your blood pressure medications exactly as your doctor prescribed them." You are palpating a client's precordium. Which of the following is an expected clinical finding? Palpable pulsation over the mitral area The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment finding that should be documented and reported to the physician? Decreased heart rate. Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus arrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S3 heart sound. The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? Each lub-dub is one beat. Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate. The charge nurse is observing a new nurse perform an assessment of a patient's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene? Palpation of both carotid arteries at the same time A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's: peripheral pulses.