NURSING FINAL EXAM Questions Graded A+!!! With Complete Solutions

How can you estimate a client's tidal volume? - ANS Tidal volume can be estimated by observing the depth of the client's respirations. What is the range of normal for an adult's respiratory rate? - ANS A rate of 12 to 20 breaths per minute is normal for adults Besides the rate, what other characteristics of a client's respirations should you observe? - ANS Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to rate. What are some common clinical signs associated with poor oxygenation? - ANS Pallor or cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation. Which of the Korotkoff sounds would you record as the systolic pressure? - ANS First Which of the Korotkoff sounds would you record as the diastolic pressure? - ANS Fifth A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately. At 150 mm Hg, the sound appears again and continues until there is silence at 80 mm Hg. The pressures were taken in the client's right arm while the client was lying down. How should the nurse record these pressures? - ANS BP RA, supine, 170/80 with an auscultatory gap from 170 to 150 How do you explain what happened? - ANS An auscultatory gap occurred. A gap is most commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal limit of 140 mm Hg. Which of the following patients has hypertension? One with a BP of: 150/80 on two separate occasions 180/100 on one occasion 138/88 on two occasions - ANS 150/80 on two separate occasions Which of the following client(s) has/have primary hypertension? Client A, who is obese and has a high sodium intake Client B, who is in renal failure Client C, who has hypertension induced by pregnancy Client D, who has a family history of hypertension - ANS Client D, who has a family history of hypertension What are five functions of the skin? - ANS The skin serves five functions: protection, sensation, temperature regulation, secretion/excretion, and formation of vitamin D. How does the skin help regulate body temperature? - ANS The skin contains sensory organs or receptors for heat and cold. The skin regulates temperature through the process of dilating and constricting blood vessels and activating or inactivating sweat glands. The sweat glands found in the axillae and external genitalia secrete fatty acids and proteins and excrete perspiration, which produces a cooling effect as the moisture evaporates from the skin. What changes take place in the skin as a person ages - ANS With age, both layers of the skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly, and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity of hair follicles and pigment cells (melanocytes) diminishes, hair becomes thin, turns gray or white, and grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin problems. True or false: The professional nurse is responsible for making assessments. - ANS True True or false: Assisting with the bath is an excellent time to assess the patient. - ANS True To inspect for pallor in a dark-skinned person, which areas would you assess for an ashen gray or yellow color? - ANS For dark-skinned persons, the conjunctivae, buccal mucosa, tongue, lips, nail beds, palms, and soles should be assessed for pallor. What is the term that means "a bluish color of the skin"? - ANS Cyanosis means a bluish discoloration of the skin. Name two causes of erythema. - ANS Vasodilation and inflammation are causes of erythema. Where can you best see jaundice? - ANS The sclera of the eyes is the best place to see jaundice