TEST 2 REVIEW QUESTIONS

Question 1

When the nurse assesses a 78-year-old patient with pneumonia, what is the priority assessment?

A.Breath sounds
B.Airway patency
C.Respiratory rate
D.Percussion sounds

Answer 1

B

Question 2

A 45-year-old man has been admitted to the hospital with suspicion of PE. Which of the following symptoms should the nurse report to the primary health practitioner immediately?

A.Chest pain
B.Shortness of breath
C.Respirations 20 breaths/min
D.Productive cough

Answer 2

A

Question 3

A 62-year-old woman comes to the clinic with an exacerbation of asthma. Which of the following findings indicate worsening status of her asthma?

A.Increased wheezing
B.Sustained rhonchi
C.Decreased respirations
D.Oxygen saturation 94%

Answer 3

A

Question 4

A 3-year-old boy is brought to the emergency department with stridor, nasal flaring, intercostal and supraclavicular retractions, and respiratory rate of 40 breaths/min. What type of situation is this?

A.Stable
B.Acute
C.Urgent
D.Emergency

Answer 4

D

Question 5

A 92-year-old woman with a history of COPD presents with increasing shortness of breath, decreased lung sounds in the bases, increased ankle edema, and 5-lb weight gain in 1 week. What is the most likely problem?

A.Impaired gas exchange
B.Ineffective airway clearance
C.Activity intolerance
D.Excess fluid volume

Answer 5

D

Question 6

Which of the following factors is the most significant risk factor for COPD?

A.Increased age
B.Immune suppression
C.Tobacco smoking
D.Occupational exposure

Answer 6

C

Question 7

When the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first?

A.Chest soreness
B.Dyspnea
C.Cough
D.Sputum

Answer 7

B

Question 8

When assessing a patient with atelectasis, what assessment findings are expected? Choose all that apply.

A.Shortness of breath
B.Decreased breath sounds
C.Decreased oxygen saturation
D.Increased tactile fremitus
E.Hyperresonance

Answer 8

A, B, C, D

Question 9

Which assessment findings would indicate that inhaled bronchodilators have been effective

A.Expiratory wheezing, O2 saturation 94%, pallor
B.Vesicular breath sounds, O2 saturation 96%, pink
C.Bronchial breath sounds, O2 saturation 100%, erythema
D.Crackles, O2 saturation 90%, circumoral cyanosis

Answer 9

B

Question 10

The nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. The nurse interprets this as

A.a normal finding over the trachea.
B.a normal finding over the bronchi.
C.an abnormal finding over the lung.
D.an abnormal finding over the trachea.

Answer 10

B

Question 11

Which of the following statements describes the cardiovascular system most accurately?

A.It is a double pump circulating blood out to the lungs and body.
B.It has a heart with six chambers, great vessels, and valves.
C.It includes concepts of precontractility, postcontractility, and load.
D.It functions with a conduction system that starts in the ventricles.

Answer 11

A

Question 12

In a healthy patient, the myocardial cells in the ventricle depolarize and contract during

A.prediastole.
B.diastole.
C.systole.
D.postsystole.

Answer 12

C

Question 13

When the nurse listens to S1 in the mitral and tricuspid areas, the expected finding is

A.S1 greater than S2.
B.S1 is equal to S2.
C.S2 greater than S1.
D.No S1 is heard

Answer 13

A

Question 14

The nurse assesses the neck vessels in the stable patient with heart failure to determine which of the following?

A.The bilateral carotid pulse
B.The presence of bruits
C.The highest level of jugular venous pulsation
D.The strength of the jugular veins

Answer 14

C

Question 15

The nurse is caring for a patient with a sudden onset of chest pain. Which assessment is highest priority?

A.Auscultate heart sounds.
B.Inspect the precordium.
C.Percuss the left border.
D.Obtain pulse and blood pressure.

Answer 15

D

Question 16

A patient who visits the clinic has the controllable risk factors of smoking, high-fat diet, overweight, decreased activity, and high blood pressure. What concept should the nurse use when performing patient teaching?

A.Teach the patient the most serious information.
B.Give the patient brochures to review before the next visit.
C.Discuss risk factors that the patient is interested in modifying.
D.Describe consequences of risk factors to motivate the patient.

Answer 16

C

Question 17

Which of the following clusters of symptoms are common in women preceding an MI?

A.Chest pain, nausea, diaphoresis
B.Weight gain, edema, nocturia
C.Dizziness, palpitations, low pulse
D.Fatigue, difficulty sleeping, dyspnea

Answer 17

D

Question 18

The nurse auscultates a medium-loud whooshing sound that softens between S1 and S2. The nurse documents this finding as which of the following?

A.Grade III systolic murmur
B.Grade I systolic murmur
C.Grade V diastolic murmur
D.Grade II diastolic murmur

Answer 18

A

Question 19

The nurse auscultates an extra sound on a patient 1 week after an MI. It is immediately after S2 and is heard best at the apex. Which of the following does the nurse suspect?

A.S3 gallop
B.S4 gallop
C.Systolic ejection click
D.Split S2

Answer 19

A

Question 20

A patient has dyspnea, edema, weight gain, and liquid intake greater than output. These symptoms are consistent with which nursing diagnosis?

A.Ineffective cardiac tissue perfusion
B.Decreased cardiac output
C.Impaired gas exchange
D.Excess fluid volume

Answer 20

D

Question 21

Which of the following is a normal ABI?

A.56
B.87
C.1.0
D.24

Answer 21

C

Question 22

Which of the following peripheral vascular diseases is not known to have a hereditary component?

A.Lymphadenopathy
B.Raynaud disease
C.Abdominal aortic aneurysm
D.PAD

Answer 22

B

Question 23

When assessing the lower extremities, it is critical that the examiner

A.starts at the feet.
B.compares side to side.
C.evaluates the venous system and then the arterial system.
D.starts at the femoral area.

Answer 23

B

Question 24

The seven Ps of an acute arterial occlusion include

A.polythermia.
B.popliteal pallor.
C.poikilothermia.
D.pitting edema.

Answer 24

C

Question 25

A history of smoking has an extremely significant role in the development of which of the following?

A.Venous insufficiency
B.DVT
C.PAD
D.Raynaud disease

Answer 25

C

Question 26

A dorsalis pedis of +1/4 may indicate

A.DVT.
B.PAD.
C.Raynaud disease.
D.Lymphadenopathy.

Answer 26

B

Question 27

During history taking, a patient reports cramping in his calf when walking a few blocks. He states that it goes away when he sits down for a few minutes. How would the nurse document this symptom?

A.Intermittent claudication
B.Rest pain
C.Poikilothermia
D.Venous stasis

Answer 27

A

Question 28

A patient reports swelling in her ankles. How would the nurse proceed with physical examination?

A.Have the patient elevate her feet to better visualize her ankles.
B.Measure her ankles at their widest point.
C.Evaluate further for the brown hyperpigmentation associated with venous insufficiency.
D.Press the fingers in the edematous area evaluating for a remaining indentation after the nurse removes his or her fingers.

Answer 28

D

Question 29

While evaluating the inguinal lymph nodes of a patient, the nurse palpates a 1-cm (about ½-in.) soft and freely movable node. What action should the nurse take next?

A.Nothing—this finding is normal.
B.Refer this patient to a specialist.
C.Immediately check the patient’s dorsalis pedis pulse.
D.Refer the patient for immediate management of a life-threatening condition.

Answer 29

A

Question 30

A patient with diabetes mellitus who closely monitors and controls her blood glucose level is very interested in preventing complications of her illness. Which teaching is a priority for the patient related to peripheral vascular circulation?

A.How to count calories.
B.How to assess her feet daily.
C.Choosing complex carbohydrates
D.Identifying venous insufficiency.

Answer 30

B