Nokea
When assessing a patient the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position the patient is able to breathe more easily. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Orthopnea
Correct Answer: D
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.
You may also like to solve these questions
When performing a physical examination of a patient the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?
- A. Auscultation
- B. Deep palpation
- C. Light palpation
- D. Percussion
Correct Answer: B
Rationale: Deep palpation is used to detect tenderness or masses of the abdomen.
When auscultating the chest a nurse hears crackles in both lower lobes. To further assess this finding the nurse should ask the patient to ____.
Correct Answer: cough
Rationale: It is a useful assessment to determine that the patient can clear the secretions by coughing.
A creamy viscous pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of ____ is known as purulent drainage.
Correct Answer: tissues
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.
When assessing a patient the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding?
- A. Skin pallor
- B. Pruritus
- C. Sallow skin
- D. Jaundice
Correct Answer: A
Rationale: Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.
During a physical assessment the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding?
- A. Bleeding in the upper intestinal tract
- B. Bleeding in the lower intestinal tract
- C. Bleeding in the entire intestinal tract
- D. Consumption of cranberry juice
Correct Answer: B
Rationale: Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.