Nokea
Which of the following landmarks are used in anterior chest auscultation of the breath sounds?
- A. Right midscapular line
- B. Costovertebral angle
- C. Left midclavicular line
- D. Midsternal line
- E. Midspinal line
Correct Answer: C,D
Rationale: Anterior chest auscultation uses the midclavicular and midsternal lines as landmarks.
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At which posterior intercostal space are the lung bases located during full inspiration?
- A. 1st
- B. 5th
- C. 8th
- D. 10th
- E. 12th
Correct Answer: D
Rationale: The lung bases extend to the 10th intercostal space posteriorly during full inspiration.
Which of the following are the most important respiratory findings on a postoperative patient several hours after she has returned to her room that need immediate attention?
- A. Crackles posteriorly
- B. Dyspnea
- C. Orthopnea
- D. Respiratory rate 24
- E. Pulse oximeter reading 92% on room air
- F. Pulse rate 88
- G. Cyanotic
Correct Answer: B,C,G
Rationale: Dyspnea, orthopnea, and cyanosis indicate respiratory distress, requiring immediate intervention.
When lightly palpating the abdomen, you notice a pulsation midline. What is the most important thing to do?
- A. Report it to the primary nurse or supervisor
- B. Document the findings
- C. Continue to palpate the abdomen using deep palpation
- D. Complete the physical assessment and document the findings
- E. Immediately discontinue the palpation
Correct Answer: E
Rationale: A midline pulsation may indicate an abdominal aortic aneurysm; stopping palpation prevents potential rupture.
You have auscultated fine crackles in both the right and left lower lobes in a postoperative patient. What is the longest period of time you should allow to pass before you auscultate the breath sounds again?
- A. 1 hour
- B. 2 hours
- C. 3 hours
- D. 4 hours
- E. 5 hours
- F. 8 hours
Correct Answer: A
Rationale: Crackles may indicate fluid overload or atelectasis, requiring reassessment within 1 hour to monitor changes.
Which of the following assessments would be included in a focused cardiovascular assessment?
- A. Radial pulse
- B. Range of motion of extremities
- C. Vital signs
- D. Pupillary reaction to light
- E. Edema of extremities
- F. Neck vein distention
- G. Heart sounds
Correct Answer: A,C,E,F,G
Rationale: Cardiovascular assessment includes pulse, vital signs, edema, neck vein distention, heart sounds, and extremity color/warmth.