Nokea
Which lobe(s) of the lungs is(are) not accessible for auscultation posteriorly?
- A. The left upper lobe
- B. The left lower lobe
- C. The right upper lobe
- D. The right middle lobe
- E. The right lower lobe
Correct Answer: D
Rationale: The right middle lobe is located anteriorly and laterally, not accessible posteriorly.
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What type of assessment is performed on admission?
- A. A focused assessment
- B. An initial head-to-toe shift assessment
- C. A comprehensive health assessment
- D. A brief admission systems assessment
- E. Disease and injury assessment
Correct Answer: B,C
Rationale: A comprehensive health assessment (C) is typically performed on admission to gather baseline data, often including an initial head-to-toe shift assessment (B) to evaluate all body systems.
Describe the assessments that should be performed in relation to these limited data.
- A. Skin turgor, mucous membrane moisture, pressure ulcer risk
- B. Capillary refill, weight, urine output
- C. Edema, skin integrity, mobility
- D. All of the above
Correct Answer: D
Rationale: For a dehydrated, bedridden patient, assess skin turgor, mucous membranes, pressure ulcer risk, capillary refill, weight, urine output, edema, skin integrity, and mobility.
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.
Which of the following would be the most accurate description of dorsal flexion assessment?
- A. Ask the patient to press his or her toes toward the foot of the bed, applying pressure against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- B. Ask the patient to pull his or her toes toward the head, pulling against the palms of your hands so you can assess the strength and equality of the flexion between the two sides
- C. Ask the patient to gently point his or her toes toward the foot of the bed so you can assess agility and coordination of the lower extremities
- D. Ask the patient to gently point his or her toes toward the head so you can assess the neuromuscular activity of his lower extremities
Correct Answer: B
Rationale: Dorsal flexion involves pulling the toes toward the head, assessed for strength and equality against resistance.
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.