Nokea
Explain the importance of performing an initial shift assessment within the first hour of your shift.
- A. Ensures early detection of changes in patient condition
- B. Establishes a baseline for comparison
- C. Guides care planning and interventions
- D. All of the above
Correct Answer: D
Rationale: An initial shift assessment within the first hour establishes a baseline, detects changes, and guides care planning.
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You have just completed auscultation of the patient's lungs. The sounds that you heard were sort of rattling; however, they cleared when the patient coughed. What term accurately describes what you heard?
- A. Crackles
- B. Rhonchi
- C. Wheezes
- D. Pleural friction rub
- E. Stridor
Correct Answer: B
Rationale: Rhonchi are rattling sounds that often clear with coughing, indicating mucus in the larger airways.
Which of the following assessment findings may provide you with neurological status data?
- A. Thick, dirty hair
- B. Lethargy
- C. Color of the lower extremities
- D. Edema of the left hand and arm
- E. Pulse rate of 44 bpm
Correct Answer: B
Rationale: Lethargy is a neurological finding indicating altered mental status, while other options relate to physical appearance or circulatory issues.
The cone portion of each lung extends approximately 1 inch above the medial aspect of the clavicle and is called what?
- A. Lower lobe
- B. PMI
- C. Bronchus
- D. Apex
- E. Base
Correct Answer: D
Rationale: The apex is the top portion of the lung extending above the clavicle.
While assessing the patient's oral mucosa, you detect severely unpleasant sour breath. What is the correct medical terminology for this finding?
- A. Halitosis
- B. Fetor oris
- C. Malodor
- D. Xerostomia
Correct Answer: A
Rationale: Halitosis is the medical term for bad breath, including sour or unpleasant odors from the mouth.
Another nurse working on your floor reports that one of the patients has an apical pulse of 87 bpm and a pulse deficit of 9. You know that means the patient's radial pulse was
- A. 96 bpm
- B. 87 bpm with 9 skips
- C. 78 bpm
- D. 9 bpm
Correct Answer: C
Rationale: Pulse deficit is the difference between apical and radial pulse rates; 87 bpm (apical) - 9 = 78 bpm (radial).