NSG 211 Final Exam CORRECT 100%
When auscultating the lung sounds how should you hold the stethoscope? -
ANSWERpeace sign
Where is the aortic valve auscultated at? - ANSWER2nd intercostal space, right sternal
border
Where would you auscultate the pulmonic valve at? - ANSWER2nd intercostal space,
left sternal border
Where would you ascultate Erb's point? - ANSWER3rd intercostal space, left sternal
Where would you auscultate the tricuspid valve? - ANSWER4th intercostal space, left
sternal border
Where would you auscultate the mitral valve? - ANSWER5th intercostal space, left
midclavicular line
What is subjective data? - ANSWERdata that cannot be measured or observed
-ex: pain
What is objective data? - ANSWERmeasurable data
-Ex: bp 120/80
How is reflexes graded? - ANSWER4/4
-the higher the number the more hyper the reflex is
-2/4 is normal
Why are electronic health records good? - ANSWERit is real time, prevents errors, and
everyone can look at it so it helps with communicate.
What is SBAR? - ANSWERsituation, background, assessment, recommendations
-we use it to talk to doctors
What is referred pain? - ANSWERpain in another body region that is caused by another
body system
-ex: arm pain due to heart attack
What is phantom pain? - ANSWERpain in a body part that is no longer present.
-ex: a limb was cut off but it is still hurting
What is visceral pain? - ANSWERorgan pain
, Why would a nurse recommend an individual to take protein? - ANSWERprotein helps
wound healing, muscle growth
Who should take protein? - ANSWERathletes, and adolescents, elderly with wounds
What is a modifiable risk factor? - ANSWERA factor that can be changed
-weight, substance abuse, smoking
What is a nonmodifiable risk factor? - ANSWERcannot be changes
-genetics, age, gender
If a patient has a suspected spinal injury, what should the nurse do? - ANSWERstabilize
the spine and reduce moving the patient as much as possible
What is tinnitus? - ANSWERringing in the ears
What is vertigo? - ANSWER-spinning
What can we educate patients with vertigo about? - ANSWERlay down and focus on an
object to make vertigo better.
What is the first signs of dehydration? - ANSWERchapped lips, thirst
A nurse is asking the student when the best time to perform a comprehensive
assessment would be. The student would answer: - ANSWERon admission to establish
a baseline of patient care
A patient prevents with the worst headache of their life to the emergency department.
What kind of assessment would the nurse perform? - ANSWERfocused assessment
A student is undergoing clinicals in the nursing home when the instructor asks the
student to determine where the patient is on the Braden scale. The student nurse knows
the Braden scale tests for the risk of what? - ANSWERskin breakdown
A disoriented patient scored high on the Morris scale. The nurse knows this means she
should do what when leaving the patient's room. - ANSWER-Morris's scale = fall risks
-lower the bed, put the call light in reach, make sure the bed alarm is on and working.
The Glasgow's Coma Scale (GCS) tests what? - ANSWERlevel of consciousness
When performing an assessment on a 50-year-old male who recently became a widow.
The nurse notes that he is very disoriented, he is wearing dirty clothes, and his breath
distinctly smells like rubbing alcohol. The nurse would use what assessment method for
this patient? - ANSWERCAGE - alcohol risk
When auscultating the lung sounds how should you hold the stethoscope? -
ANSWERpeace sign
Where is the aortic valve auscultated at? - ANSWER2nd intercostal space, right sternal
border
Where would you auscultate the pulmonic valve at? - ANSWER2nd intercostal space,
left sternal border
Where would you ascultate Erb's point? - ANSWER3rd intercostal space, left sternal
Where would you auscultate the tricuspid valve? - ANSWER4th intercostal space, left
sternal border
Where would you auscultate the mitral valve? - ANSWER5th intercostal space, left
midclavicular line
What is subjective data? - ANSWERdata that cannot be measured or observed
-ex: pain
What is objective data? - ANSWERmeasurable data
-Ex: bp 120/80
How is reflexes graded? - ANSWER4/4
-the higher the number the more hyper the reflex is
-2/4 is normal
Why are electronic health records good? - ANSWERit is real time, prevents errors, and
everyone can look at it so it helps with communicate.
What is SBAR? - ANSWERsituation, background, assessment, recommendations
-we use it to talk to doctors
What is referred pain? - ANSWERpain in another body region that is caused by another
body system
-ex: arm pain due to heart attack
What is phantom pain? - ANSWERpain in a body part that is no longer present.
-ex: a limb was cut off but it is still hurting
What is visceral pain? - ANSWERorgan pain
, Why would a nurse recommend an individual to take protein? - ANSWERprotein helps
wound healing, muscle growth
Who should take protein? - ANSWERathletes, and adolescents, elderly with wounds
What is a modifiable risk factor? - ANSWERA factor that can be changed
-weight, substance abuse, smoking
What is a nonmodifiable risk factor? - ANSWERcannot be changes
-genetics, age, gender
If a patient has a suspected spinal injury, what should the nurse do? - ANSWERstabilize
the spine and reduce moving the patient as much as possible
What is tinnitus? - ANSWERringing in the ears
What is vertigo? - ANSWER-spinning
What can we educate patients with vertigo about? - ANSWERlay down and focus on an
object to make vertigo better.
What is the first signs of dehydration? - ANSWERchapped lips, thirst
A nurse is asking the student when the best time to perform a comprehensive
assessment would be. The student would answer: - ANSWERon admission to establish
a baseline of patient care
A patient prevents with the worst headache of their life to the emergency department.
What kind of assessment would the nurse perform? - ANSWERfocused assessment
A student is undergoing clinicals in the nursing home when the instructor asks the
student to determine where the patient is on the Braden scale. The student nurse knows
the Braden scale tests for the risk of what? - ANSWERskin breakdown
A disoriented patient scored high on the Morris scale. The nurse knows this means she
should do what when leaving the patient's room. - ANSWER-Morris's scale = fall risks
-lower the bed, put the call light in reach, make sure the bed alarm is on and working.
The Glasgow's Coma Scale (GCS) tests what? - ANSWERlevel of consciousness
When performing an assessment on a 50-year-old male who recently became a widow.
The nurse notes that he is very disoriented, he is wearing dirty clothes, and his breath
distinctly smells like rubbing alcohol. The nurse would use what assessment method for
this patient? - ANSWERCAGE - alcohol risk
