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A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.
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A nurse is caring for a patient with congestive heart failure. During the physical assessment the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: A
Rationale: Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety.
Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine?
- A. Sounds for auscultation
- B. Data about physical features
- C. Changes in structural integrity
- D. Density of underlying tissue
Correct Answer: D
Rationale: The sounds indicate the density of the underlying tissue.
During a physical assessment the nurse listens for adventitious lung sounds. Crackles are classified as fine medium or coarse. When are these sounds most often auscultated?
- A. During expiration
- B. Following expiration
- C. During inspiration
- D. Following inspiration
Correct Answer: C
Rationale: Crackles are usually heard during inspiration.
The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease?
- A. Pituitary
- B. Adrenals
- C. Pancreas
- D. Thyroid
Correct Answer: C
Rationale: Diabetes mellitus results from dysfunction of the pancreas.
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds the nurse identifies 2+ pitting edema. When did the edema disappear?
- A. 10 to 15 seconds
- B. 20 to 25 seconds
- C. 30 to 35 seconds
- D. 40 to 45 seconds
Correct Answer: A
Rationale: The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.