NURS 3080 Exam 2 Study Guide With
Complete Solution
A barrel chest and hyper resonance upon auscultation would be an expected
assessment finding in a patient with what disease? - ANSWER Emphysema
When suctioning a patient, what is the maximum time allowed to complete
one cycle of suctioning? - ANSWER 12-15 seconds
During percussion, the nurse knows that a dull percussion note elicited over a
lung lobe most likely results of? - ANSWER Increased density of the lung
Right upper quadrant tenderness may indicate pathology in the: - ANSWER
liver, pancreas, or ascending colon
A patient is dyspneic with a respiratory rate of 26 breaths per minute. What
is the healthcare provider's first action? - ANSWER Raise the head of the bed
to a 45 degree angle
Hyperactive bowel sounds are: - ANSWER all of the above
high pitched, rushing, tinkling
Which of the following may be noted through inspection of the abdomen? -
ANSWER Venous pattern, peristaltic waves, and abdominal contour
Striae, which occur when the elastic fibers in the reticular layer of the skin are
broken after rapid or prolonged stretching, have a distinct color when of
long duration. This color is: - ANSWER Silvery White
The nurse hears high pitched, musical squeaking sounds when listening to a
,patient's lung sounds. The nurse knows that this is most likely from what? -
ANSWER Bronchial constriction
When evaluating a patient's posterior thorax excursions, the nurse notices
her right hand does not move when the patient deeply inhales. What is the
significance of this result? - ANSWER The right lung is not expanding with
inhalation
A patient comes in the clinic for a routine breast and axilla exam. Which
assessment technique does the nurse use first during the examination? -
ANSWER Inspection
The most common site of breast tumors is: - ANSWER Upper outer quadrant
Which of the following accurately describes constipation? - ANSWER All of
the above
The nurse knows the most nutrients are absorbed in which portion of the
digestive tract? - ANSWER Duodenum
The nurse is caring for a patient who has diarrhea. What is the priority
nursing diagnosis? - ANSWER Deficient fluid volume related to excessive loss
of fluid through stool.
A patient has hyperactive bowel sounds. The nurse knows that a potential
cause of hyperactive bowel sounds is: - ANSWER Gastroenteritis
The nurse is caring for a patient who is recovering from bowel surgery.
Which assessment finding best indicates that the bowel is starting to resume
function and the patient will be able to resume oral intake soon? - ANSWER
The patient has bowel sounds times 4 quadrants and is passing gas.
The nurse is caring for a patient with a colostomy. Which intervention is most
, important? - ANSWER Selecting a bag with an appropriate size stoma
opening.
The nurse is caring for a patient who has just completed 2 weeks of IV
antibiotics for a severe infection. The patient has frequent loose watery
stools and a low grade temperature. What is the most likely cause of the
patient's new symptoms? - ANSWER C. difficile infection
A nurse is performing a breast exam on a patient. The nurse asks the patient
to raise her hands above her head. Why did the nurse change the patient's
position? - ANSWER Skin dimpling is accented in this postion
Where is the apical impulse located? - ANSWER Fifth intercostal space at the
midclavicular line
What technique would be appropriate to incorporate when assessing the
carotid artery? - ANSWER Use the bell of the stethoscope
When conducting an Allen test, what veins or arteries are you testing? -
ANSWER Radial
Following a client's femoral-popliteal bypass surgery, which of the following
pulse points would be most useful for determining the post-operative
perfusion of the affected limb? - ANSWER Dorsalis Pedis
Complete Solution
A barrel chest and hyper resonance upon auscultation would be an expected
assessment finding in a patient with what disease? - ANSWER Emphysema
When suctioning a patient, what is the maximum time allowed to complete
one cycle of suctioning? - ANSWER 12-15 seconds
During percussion, the nurse knows that a dull percussion note elicited over a
lung lobe most likely results of? - ANSWER Increased density of the lung
Right upper quadrant tenderness may indicate pathology in the: - ANSWER
liver, pancreas, or ascending colon
A patient is dyspneic with a respiratory rate of 26 breaths per minute. What
is the healthcare provider's first action? - ANSWER Raise the head of the bed
to a 45 degree angle
Hyperactive bowel sounds are: - ANSWER all of the above
high pitched, rushing, tinkling
Which of the following may be noted through inspection of the abdomen? -
ANSWER Venous pattern, peristaltic waves, and abdominal contour
Striae, which occur when the elastic fibers in the reticular layer of the skin are
broken after rapid or prolonged stretching, have a distinct color when of
long duration. This color is: - ANSWER Silvery White
The nurse hears high pitched, musical squeaking sounds when listening to a
,patient's lung sounds. The nurse knows that this is most likely from what? -
ANSWER Bronchial constriction
When evaluating a patient's posterior thorax excursions, the nurse notices
her right hand does not move when the patient deeply inhales. What is the
significance of this result? - ANSWER The right lung is not expanding with
inhalation
A patient comes in the clinic for a routine breast and axilla exam. Which
assessment technique does the nurse use first during the examination? -
ANSWER Inspection
The most common site of breast tumors is: - ANSWER Upper outer quadrant
Which of the following accurately describes constipation? - ANSWER All of
the above
The nurse knows the most nutrients are absorbed in which portion of the
digestive tract? - ANSWER Duodenum
The nurse is caring for a patient who has diarrhea. What is the priority
nursing diagnosis? - ANSWER Deficient fluid volume related to excessive loss
of fluid through stool.
A patient has hyperactive bowel sounds. The nurse knows that a potential
cause of hyperactive bowel sounds is: - ANSWER Gastroenteritis
The nurse is caring for a patient who is recovering from bowel surgery.
Which assessment finding best indicates that the bowel is starting to resume
function and the patient will be able to resume oral intake soon? - ANSWER
The patient has bowel sounds times 4 quadrants and is passing gas.
The nurse is caring for a patient with a colostomy. Which intervention is most
, important? - ANSWER Selecting a bag with an appropriate size stoma
opening.
The nurse is caring for a patient who has just completed 2 weeks of IV
antibiotics for a severe infection. The patient has frequent loose watery
stools and a low grade temperature. What is the most likely cause of the
patient's new symptoms? - ANSWER C. difficile infection
A nurse is performing a breast exam on a patient. The nurse asks the patient
to raise her hands above her head. Why did the nurse change the patient's
position? - ANSWER Skin dimpling is accented in this postion
Where is the apical impulse located? - ANSWER Fifth intercostal space at the
midclavicular line
What technique would be appropriate to incorporate when assessing the
carotid artery? - ANSWER Use the bell of the stethoscope
When conducting an Allen test, what veins or arteries are you testing? -
ANSWER Radial
Following a client's femoral-popliteal bypass surgery, which of the following
pulse points would be most useful for determining the post-operative
perfusion of the affected limb? - ANSWER Dorsalis Pedis
