Nokea
Describe the assessments that should be performed in relation to these limited data.
- A. Skin turgor, mucous membrane moisture, pressure ulcer risk
- B. Capillary refill, weight, urine output
- C. Edema, skin integrity, mobility
- D. All of the above
Correct Answer: D
Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.
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Abnormal sounds that can be auscultated over the lung fields are called
- A. Crackles
- B. Wheezes
- C. Rhonchi
- D. Stridor
- E. Pleural friction rub
Correct Answer: A,B,C,D,E
Rationale: Abnormal lung sounds include crackles (rattling sounds), wheezes (high-pitched whistling), rhonchi (low-pitched rattling), stridor (high-pitched sound during breathing), and pleural friction rub (grating sound due to pleural inflammation).
Which lobe(s) of the lungs is(are) not accessible for auscultation posteriorly?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: D
Rationale: The right middle lobe is located anteriorly and laterally, not accessible posteriorly.
You are preparing to perform an initial shift assessment. You know that the correct order in which you should perform the five techniques for objective assessment (except for the abdomen) is
- A. Auscultation, olfaction, observation, palpation, and percussion
- B. Observation, auscultation, palpation, percussion, and olfaction
- C. Observation, palpation, percussion, auscultation, and olfaction
- D. Olfaction, auscultation, observation, palpation, and percussion
- E. Olfaction, observation, auscultation, percussion, and palpation
Correct Answer: B
Rationale: The correct order for assessment (except abdomen) is observation, auscultation, palpation, percussion, and olfaction to avoid altering findings.
Which lobe(s) of the lungs is(are) accessible for auscultation only posteriorly and laterally?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: B,E
Rationale: The left and right lower lobes are accessible posteriorly and laterally due to their anatomical position.
The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this?
- A. Palpate a radial pulse in both wrists for 30 seconds
- B. Auscultate the apical pulse for 60 seconds
- C. Take a second nurse with you to palpate the radial pulse at the same time that you auscultate the apical pulse for 60 seconds
- D. Palpate the PMI for a full minute
Correct Answer: B
Rationale: Auscultating the apical pulse for 60 seconds provides the most accurate heart rate, especially for irregular rhythms.