Nokea
While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
- A. crackles
- B. Rales
- C. adventitious sounds
- D. pleral friction rub
Correct Answer: C
Rationale: Continuous abnormal lung sounds are charted as adventitious, encompassing wheezes or rubs, unlike intermittent crackles or rales. Pleural rub is specific. Nurses document this for respiratory evaluation.
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Which of the following is NOT true about BP?
- A. BP is dependent on blood volume, Cardiac output and peripheral resistance
- B. BP is dependent on age and body weight
- C. The BP on the left arm is higher than the right
- D. BP is taken on the left arm because it is nearest to the heart
Correct Answer: C
Rationale: BP depends on blood volume, cardiac output, and peripheral resistance (A), and varies with age and weight (B), per cardiovascular physiology. The left arm isn't inherently higher (C) it's false; differences are minimal and individual. Left arm use (D) is convention, not proximity (it's not significantly closer). C's absolute claim lacks evidence, making it the untrue statement, as BP symmetry is typical unless pathology exists.
Which of the following is TRUE about the blood pressure determinants?
- A. Hypervolemia lowers BP
- B. Hypervolemia increases GFR
- C. HCT of 70% might decrease or increase BP
- D. Epinephrine decreases BP
Correct Answer: C
Rationale: Hematocrit (HCT) 70% e.g., polycythemia can raise BP (viscosity) or lower it (poor flow), unlike hypervolemia (raises BP, GFR), or epinephrine (raises BP). Nurses assess this e.g., in anemia for variable impacts, per circulatory dynamics.
Which of the following is an example of relaxation technique?
- A. Guided imagery
- B. Distraction
- C. TENS
- D. Acupuncture
Correct Answer: A
Rationale: Guided imagery (A) is a relaxation technique, calming via imagined scenes, per pain management categories. Distraction (B) diverts attention, TENS (C) uses electrical stimulation, acupuncture (D) needles none primarily relax. A reduces tension and stress, fitting relaxation's goal, making it the correct example.
The nurse recorded Mr. Gary's vitals in his chart. This is an example of?
- A. Documentation
- B. Standard precautions
- C. Health policy
- D. Patient education
Correct Answer: A
Rationale: Recording vitals is documentation (A) care record, per definition. Precautions (B) safety, policy (C) rules, education (D) teaching not record-specific. A fits the nurse's accurate logging for Mr. Gary, making it correct.
After a day, Mr Gary's wife shouted at the nurse and said 'You're not doing your job right! My husband is dying because of you!' This is an example of?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: B
Rationale: Shouting 'You're not doing your job is anger (B), per Kubler-Ross lashing out in grief. Denial (A) rejects, bargaining (C) pleads, depression (D) withdraws. Anger targets others, fitting her outburst, making it correct.