Assessment Questions and Answers 100%
Correct [Grade A]– Chamberlain
What information should be recorded in the Cardiovascular portion of the I-SBAR
Assessment section? Select all that apply. - correct answer Cardiac sounds s1s2 WNL
No carotid bruit noted
The nurse enters the room to perform a focused respiratory assessment. The
assessment reveals the following assessment findings.
Drag the assessment findings that require further follow-up to the box on the right. -
correct answer Absent lung sounds on right
Inspiratory wheezes
Accessory muscle use
The nurse continues with the focused assessment and palpates Ms. Jones's thorax.
When palpating the thorax, which findings are abnormal? Select all that apply. -
correct answer Asymmetrical chest expansion
Masses
Tenderness
Reflect on the head-to-chest skill video you watched earlier. Place the steps of
respiratory system assessment in the correct order: - correct answer Nurse inspects
anterior chest for accessory muscle use
Nurse auscultates anterior lung fields
Nurse auscultates posterior lung fields
Nurse inspects anteroposterior (A/P) to transverse diameter
Nurse inspects the curvature of the spine
As part of the assessment, the nurse auscultates the client's cardiac areas. Select the
auscultatory areas corresponding to the location on the client's chest from the list of
options. - correct answer
Wheezes - correct answer Continuous musical sounds heard mainly over expiration
Decreased breath sounds - correct answer Indication of obstructed air flow
Barrel chest - correct answer Anteroposterior = transverse diameter, can indicate
hyperinflation of the lungs
Tripod position - correct answer Client is positioned leaning forward with arms braced
against their knees, chair, or bed