Nokea
What is the suggested sequence for a systematic approach to begin auscultating the thorax?
- A. Anterior thorax
- B. Apices
- C. Left lateral thorax
- D. Right lateral thorax
Correct Answer: B
Rationale: The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.
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The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched coarse gurgling and have a snoring sound. What best identifies these sounds?
- A. Crackles
- B. Plural friction rub
- C. Rhonchi
- D. Sonorous wheezes
Correct Answer: D
Rationale: Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
During a physical assessment the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Ecchymosis
Correct Answer: B
Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.
A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.
When assessing a patient with hepatitis the nurse notes a yellow tinge to the patient's skin. What does the nurse understand as the most likely cause of the jaundice?
- A. Heart
- B. Liver
- C. Brain
- D. Intestines
Correct Answer: B
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease?
- A. Pituitary
- B. Adrenals
- C. Pancreas
- D. Thyroid
Correct Answer: C
Rationale: Diabetes mellitus results from dysfunction of the pancreas.