Nokea
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.
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When performing a nursing physical assessment the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?
- A. Skin assessment
- B. Neurologic assessment
- C. Circulatory assessment
- D. Respiratory assessment
Correct Answer: B
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.
Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as ____.
Correct Answer: erythema
Rationale: Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries.
Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per minute?
- A. 2 to 10
- B. 3 to 20
- C. 4 to 32
- D. 5 to 40
Correct Answer: C
Rationale: The normal rate of bowel sounds per minute is 4 to 32.
An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min is known as ____.
Correct Answer: tachycardia
Rationale: Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min.
The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather?
- A. Flashlight
- B. Gloves
- C. Red pen
- D. Thermometer
- E. Scissors
Correct Answer: A,B,D,E
Rationale: Items essential to the nurse's assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade.