Nokea
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.
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Your instructor has asked you to come to the patient's room to hear a good example of a murmur and a bruit. You know that there are specific instances when you use the bell versus the diaphragm side on your stethoscope and when you use light pressure as opposed to pressing to make a firm seal against the patient's skin. Which of the following correctly describes how to use the bell and diaphragm chest piece of your stethoscope?
- A. Use the flat diaphragm to auscultate lower-pitched sounds
- B. Use the bell to auscultate lower-pitched sounds
- C. When using the bell, press firmly to seal it against the skin
- D. When using the flat diaphragm, press it firmly to seal it against the skin
- E. Murmurs and bruits are considered high-pitched sounds
- F. The S1 and S2 are considered high-pitched sounds
Correct Answer: B,D
Rationale: The bell is used for low-pitched sounds with light pressure, while the diaphragm is pressed firmly for high-pitched sounds like murmurs and bruits.
Percussion of a patient's abdomen and chest provides you with what information about the patient?
- A. Density of underlying structures
- B. Presence of fluid or air
- C. Organ size and position
- D. All of the above
Correct Answer: D
Rationale: Percussion reveals density, fluid, air, and organ size/position through sound differences (e.g., dullness, tympany).
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.
What assessments should you make of the lower extremities in an initial shift assessment?
- A. Pulse strength, edema, skin condition, range of motion
- B. Capillary refill, temperature, sensation, strength
- C. Color, pulses, edema, mobility
- D. All of the above
Correct Answer: D
Rationale: Lower extremity assessment includes pulse strength, edema, skin condition, range of motion, capillary refill, temperature, sensation, strength, color, and mobility.
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).