Nokea
During an assessment, you noted two new findings in a patient: unable to palpate peripheral pulse in lower extremities and pupils that are not equal in size and rate of constriction. Which of these two findings provides you with information about the neurological system?
- A. Peripheral pulses
- B. Pupils
- C. Both findings
- D. None of the above
Correct Answer: B
Rationale: Pupil size and constriction rate are neurological indicators, while peripheral pulses relate to the cardiovascular system.
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When lightly palpating the abdomen, you notice a pulsation midline. What is the most important thing to do?
- A. Report it to the primary nurse or supervisor
- B. Document the findings
- C. Continue to palpate the abdomen using deep palpation
- D. Complete the physical assessment and document the findings
- E. Immediately discontinue the palpation
Correct Answer: E
Rationale: A midline pulsation may indicate an abdominal aortic aneurysm; stopping palpation prevents potential rupture.
Which of the following landmarks are used in anterior chest auscultation of the breath sounds?
- A. Right midscapular line
- B. Costovertebral angle
- C. Left midclavicular line
- D. Midsternal line
- E. Midspinal line
Correct Answer: C,D
Rationale: Anterior chest auscultation uses the midclavicular and midsternal lines as landmarks.
At which posterior intercostal space are the lung bases located during full inspiration?
- A. 1st
- B. 5th
- C. 8th
- D. 10th
- E. 12th
Correct Answer: D
Rationale: The lung bases extend to the 10th intercostal space posteriorly during full inspiration.
Which of the following are the most important respiratory findings on a postoperative patient several hours after she has returned to her room that need immediate attention?
- A. Crackles posteriorly
- B. Dyspnea
- C. Orthopnea
- D. Respiratory rate 24
- E. Pulse oximeter reading 92% on room air
- F. Pulse rate 88
- G. Cyanotic
Correct Answer: B,C,G
Rationale: Dyspnea, orthopnea, and cyanosis indicate respiratory distress, requiring immediate intervention.
Which of the following assessments would be included in a focused cardiovascular assessment?
- A. Radial pulse
- B. Range of motion of extremities
- C. Vital signs
- D. Pupillary reaction to light
- E. Edema of extremities
- F. Neck vein distention
- G. Heart sounds
Correct Answer: A,C,E,F,G
Rationale: Cardiovascular assessment includes pulse, vital signs, edema, neck vein distention, heart sounds, and extremity color/warmth.