Nokea
The bottom of the lower lobes of the lungs extends down to which of the following?
- A. 8th intercostal space midclavicular line anteriorly
- B. 6th intercostal space laterally
- C. 10th intercostal space anteriorly
- D. 6th intercostal space midclavicular line anteriorly
- E. 8th intercostal space posteriorly
- F. 10th intercostal space laterally
Correct Answer: E,F
Rationale: The lower lobes extend to the 8th intercostal space posteriorly and 10th intercostal space laterally.
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A 5-year-old child has a fever of 104.4°F axillary. When should you reassess the child's temperature?
- A. Within 60 minutes
- B. Within 90 minutes
- C. Within 2 hours
- D. Within 4 hours
Correct Answer: A
Rationale: A high fever in a child requires reassessment within 60 minutes to monitor response to interventions and prevent complications like febrile seizures.
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.
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.
During a focused assessment of a patient's circulatory system, you were unable to palpate the left pedal pulse although the right pedal pulse was strong. What should be your first action?
- A. Notify the health-care provider
- B. Check the blood pressure in the left leg
- C. Palpate for the left posterior tibialis pulse
- D. Obtain a Doppler
Correct Answer: D
Rationale: Using a Doppler is the first step to assess an absent pedal pulse, as it can detect blood flow that is not palpable.
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.