PN006 Integrated Nursing Practice Study Set - Ultimate
Guide With Expert Solutions
The nurse should include which in a cardiovascular assessment? Right Ans
- Auscultation of lung sounds, breathing patterns, and colour of skin (all of the
above)
The nurse hears S3 sound, which would be true? Right Ans - Indicates CHF,
lubdub-y (kentucky), and best heard with the bell of the stethoscope
Pt suffered right-sided CVA 2 months ago, which may be observed? Right
Ans - Atrophy of muscles in left arm and leg, and hemiparesis of left side of
body
When administering oxygen, remember to: Right Ans - Check gauge is at
prescribed level, check tube for kinks, check to see if tank is empty, all of the
above
Patient retains CO2, they need: Right Ans - Evaluated ABGs and oxygen
with low flow rate as per doctor's order
Nurse is discussing arteriosclerosis and its effects on older adults. The most
recognized effect is on the cardiovascular system. The nurse should include
which statement regarding effects on GI system? Right Ans - The problem it
creates with blood flow also affects blood flow in the bowels, so it affects
elimination
What practice will be best to contain bacteria for a patient with C. Diff?
Right Ans - Practicing hand hygiene
Documentation in the patient progress record should include: Right Ans -
Any invasive nursing care, changes in patient's health status, response to
treatment (all of the above)
If a sweet, fruity smell is noticed in the oral cavity, the nurse should suspect:
Right Ans - Diabetic ketoacidosis
,Which assessment finding would be a risk factor for heart disease? Right
Ans - Hyperlipidemia, inadequate exercise, and smoking (all of the above)
In a cardio assessment, the nurse should pay attention to: Right Ans -
Edema, unequal pedal pulses bilaterally, cyanotic toe nails (all of the above)
What is the best way to listen to high pitched sounds? Right Ans -
Diaphragm (of stethoscope)
The nurse admitted a client to acute care unit what nursing diagnosis takes
highest priority? Right Ans - High risk for injury
Incorrect statement in older adult and cardiopulmonary function? Right
Ans - Older adults are easily bothered by dyspnea and complain to the nurse
Client with right-sided heart failure; What does the nurse expect to find?
Right Ans - Peripheral edema
Client with Alzheimers nurse knows which is the best indicator of risk of falls?
Right Ans - History of falls
What position maximizes nurses' ability to assess clients' upper symmetry?
Right Ans - Sitting
Respiratory assessments include which? Right Ans - Auscultation of breath
sounds, inspection of colour of extremities, evaluating current meds (all of the
above)
Patient is having dyspnea, mucous and cyanosis. He is 50 and has smoked for
years. What is he suffering from? Right Ans - Chronic bronchitis
Patient with COPD, order should include: Right Ans - O2 at 6L/min
continuously, sputum specimen, encourage water
Signs and symptoms of hypoxia: Right Ans - Decreased heart rate, angina,
diaphoresis
Types of enteral feeding tubes: Right Ans - Gastrostomy, jejunal,
nasogastric (all of the above)
, Normal vesicular sounds: Right Ans - Soft, breezy, low pitched
Best location to auscultate PMI? Right Ans - 5th intercostal, medial to left
S2 sound indicates: Right Ans - Closing of pulmonic and aortic valves
Patient with asthma is weak and tired, which position should patient be in for
peak expiratory flow rate (PEFR)? Right Ans - High Fowler's
Patient with COPD has dyspnea and poor gas exchange Right Ans - True
Non-rebreather mask for low oxygen of 3L/min or less: Right Ans - False
(15 L)
Where is the point of maximum impulse (PMI)? Right Ans - Apex of the
heart
How can crackles be cleared? Right Ans - Deep breathing and coughing
Define "macule": Right Ans - A flat change in skin colour such as a freckle
Patient's gait should be observed during which assessment? Right Ans -
Neuromuscular
When should you palpate painful areas in a GI assessment? Right Ans - Last
Who can the nurse assign task of vitals to? Right Ans - An unregulated
health worker
Where do you assess pallor in a dark skinned patient? Right Ans - - Gums
- Conjunctiva of eye
When is peak expiratory flow of air? Right Ans - When expiration is taken
What is the priority nursing action for a patient is experiencing respiratory
distress? Right Ans - Apply supplemental oxygen
What is the normal range for spo2? Right Ans - 95% - 100%
Guide With Expert Solutions
The nurse should include which in a cardiovascular assessment? Right Ans
- Auscultation of lung sounds, breathing patterns, and colour of skin (all of the
above)
The nurse hears S3 sound, which would be true? Right Ans - Indicates CHF,
lubdub-y (kentucky), and best heard with the bell of the stethoscope
Pt suffered right-sided CVA 2 months ago, which may be observed? Right
Ans - Atrophy of muscles in left arm and leg, and hemiparesis of left side of
body
When administering oxygen, remember to: Right Ans - Check gauge is at
prescribed level, check tube for kinks, check to see if tank is empty, all of the
above
Patient retains CO2, they need: Right Ans - Evaluated ABGs and oxygen
with low flow rate as per doctor's order
Nurse is discussing arteriosclerosis and its effects on older adults. The most
recognized effect is on the cardiovascular system. The nurse should include
which statement regarding effects on GI system? Right Ans - The problem it
creates with blood flow also affects blood flow in the bowels, so it affects
elimination
What practice will be best to contain bacteria for a patient with C. Diff?
Right Ans - Practicing hand hygiene
Documentation in the patient progress record should include: Right Ans -
Any invasive nursing care, changes in patient's health status, response to
treatment (all of the above)
If a sweet, fruity smell is noticed in the oral cavity, the nurse should suspect:
Right Ans - Diabetic ketoacidosis
,Which assessment finding would be a risk factor for heart disease? Right
Ans - Hyperlipidemia, inadequate exercise, and smoking (all of the above)
In a cardio assessment, the nurse should pay attention to: Right Ans -
Edema, unequal pedal pulses bilaterally, cyanotic toe nails (all of the above)
What is the best way to listen to high pitched sounds? Right Ans -
Diaphragm (of stethoscope)
The nurse admitted a client to acute care unit what nursing diagnosis takes
highest priority? Right Ans - High risk for injury
Incorrect statement in older adult and cardiopulmonary function? Right
Ans - Older adults are easily bothered by dyspnea and complain to the nurse
Client with right-sided heart failure; What does the nurse expect to find?
Right Ans - Peripheral edema
Client with Alzheimers nurse knows which is the best indicator of risk of falls?
Right Ans - History of falls
What position maximizes nurses' ability to assess clients' upper symmetry?
Right Ans - Sitting
Respiratory assessments include which? Right Ans - Auscultation of breath
sounds, inspection of colour of extremities, evaluating current meds (all of the
above)
Patient is having dyspnea, mucous and cyanosis. He is 50 and has smoked for
years. What is he suffering from? Right Ans - Chronic bronchitis
Patient with COPD, order should include: Right Ans - O2 at 6L/min
continuously, sputum specimen, encourage water
Signs and symptoms of hypoxia: Right Ans - Decreased heart rate, angina,
diaphoresis
Types of enteral feeding tubes: Right Ans - Gastrostomy, jejunal,
nasogastric (all of the above)
, Normal vesicular sounds: Right Ans - Soft, breezy, low pitched
Best location to auscultate PMI? Right Ans - 5th intercostal, medial to left
S2 sound indicates: Right Ans - Closing of pulmonic and aortic valves
Patient with asthma is weak and tired, which position should patient be in for
peak expiratory flow rate (PEFR)? Right Ans - High Fowler's
Patient with COPD has dyspnea and poor gas exchange Right Ans - True
Non-rebreather mask for low oxygen of 3L/min or less: Right Ans - False
(15 L)
Where is the point of maximum impulse (PMI)? Right Ans - Apex of the
heart
How can crackles be cleared? Right Ans - Deep breathing and coughing
Define "macule": Right Ans - A flat change in skin colour such as a freckle
Patient's gait should be observed during which assessment? Right Ans -
Neuromuscular
When should you palpate painful areas in a GI assessment? Right Ans - Last
Who can the nurse assign task of vitals to? Right Ans - An unregulated
health worker
Where do you assess pallor in a dark skinned patient? Right Ans - - Gums
- Conjunctiva of eye
When is peak expiratory flow of air? Right Ans - When expiration is taken
What is the priority nursing action for a patient is experiencing respiratory
distress? Right Ans - Apply supplemental oxygen
What is the normal range for spo2? Right Ans - 95% - 100%
