Nokea
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.
You may also like to solve these questions
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.
A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:
- A. a complete physical examination.
- B. a medical assessment.
- C. an individualized plan of care.
- D. writing nursing orders.
Correct Answer: C
Rationale: The information contained in the database is the basis for an individualized plan of care.
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.
As part of an assessment the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?
- A. Assessments
- B. Symptoms
- C. Signs
- D. Observations
Correct Answer: B
Rationale: Symptoms are subjective indications of illness that are perceived by the patient.
The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making?
- A. Care plan
- B. Medical diagnosis
- C. Nursing assessment
- D. Patient problem
Correct Answer: D
Rationale: Nurses rely on assessment of signs and symptoms to formulate a patient problem.