NUR 210 Final Exam | 100% Correct Answers | Verified | Latest 2024 Version, Exams of Nursing

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NUR 210 Final Exam | 100% Correct Answers |

Verified | Latest 2024 Version

Which statement best reflects evidenced-based practice (EBP)? a. EBP relies on tradition for support of best practices B. EBP is simply the use of best practice techniques for treatment of patients. c. EBP emphasizes the use of best evidence with the clinician's experience. d. the patient's own preferences are not important with EBP - ✔✔C A 59-year-old tells the nurse that he has ulcerative collitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care? A. J.M. is a 59-year-old here for "ulcerative collitis" b. J.M. came into the clinic complaining of black stools for the past 24 hours. c. J.M., a 59-year-old male states he has ulcerative collitis and wants it checked. d. J.M. is a 59-year-old male here for having black stools for the past 24 hours. - ✔✔D The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. is used to listen to high-pitched sound b. is used to listen to low-pitched sound c. should be held lightly against the person's skin to block out low pitched sounds d. should be held lightly against the person's skin to listen for extra heart sounds and murmurs. - ✔✔A Which is an example of a first-priority problem? A. a patient with postoperative pain b. a newly diagnosed diabetic who needs diabetic teaching c. an individual with a small laceration on the sole of the foot d. an individual with shortness of breath and respiratory distress - ✔✔D Which internal factors are needed in order to facilitate effective communication with clients?

A. ensuring privacy, refusing interruption, equal status seating and note taking B. open ended questions, facilitation, providing reassurance and giving advice C. confrontation, interpretation, explanation, and summary D. Liking others, empathy, the ability to listen and self-awareness - ✔✔D The nurse is nearing the end of an interview. Which statement is appropriate at this time? A. is there anything else you would like to mention? B. Did we forget something? C. I need to go on to the next patient. I'll be back D. while I am here, let's talk about the upcoming surgery. - ✔✔A The nurse is performing a general survey. Which action is a component of the general survey? A. oberserving the patient's body stature and nutrition status. B. Interpreting the subjective information the patient has responded C. measuring the patient's temp, respirations, pulse, and BP D. observing specific body systems while performing the physical assessment - ✔✔A When should the nurse perform a general survey? A. As soon as the nurse comes in contact with the client B. after the patient has completed answering all of the health history questions C. at the conclusion of the physical assessment D. after the vital signs have been obtained. - ✔✔A which technique will the nurse use to begin a physical exam? A. inspection b. palpation c. percusion d. auscultation - ✔✔A

in recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a. pt denies usual childhood illnesses b. pt states he was a "very healthy" child. c. pt states sister had measles, but he didn't d. pt denies measles, mumps, rubella, chickenpox, pertussis, and strep throat - ✔✔D What are the characteristics of bronchovesicular breath sounds? a. low pitched with longer inspiration than expiration b. high pitched with inspiration shorter than expiration c. moderate pitch with equal inspiration and expiration d. low pitched with inspiration equal to expiration - ✔✔C When auscultating lung sounds the nurse instructs the pt to a. breathe in and out through nose, deeper than normal b. breathe through the mouth, deeper than normal c. inhale through the nose, and exhale through the mouth d. breathe in and out through the nose at a normal depth - ✔✔B When obtaining subjective data regarding thorax and lungs, the nurse should include the following questions (select all that apply) a. do you have a cough? b. do you smoke cigarettes or cigars? c. are there any environmental conditions that may affect your breathing? d. when was your last TB test? e. do you ever experience shortness of breath? f. what is your favorite food? - ✔✔A, B, C, D, E white or clear sputum - ✔✔colds, bronchitis, viral infections

yellow or green sputum - ✔✔bacterial infection rust colored sputum - ✔✔TB or pneumococcal pneumonia pink frothy sputum - ✔✔pulmonary edema which statement is true regarding bronchovesicular breath sounds? a. usually pathological b. similar to bronchial sounds except that they are shorter in duration c. expected near major airways d. musical in quality - ✔✔C when auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low- pitched, soft breath sounds are heard, with inspiration being longer than expiration. the nurse interprets that these are a. sounds normally auscultated over the trachea b. bronchovesicular breath sounds are normal in that location c. vesicular breath sounds and are normal in that location d. bronchial breath sounds and are normal in that location - ✔✔C inspection of respiratory system and anterior thorax includes: (select all that apply) a. level of consciousness b. skin color and condition c. quality of respirations d. retraction or bulging of the interspaces e. breath sounds f. facial symmetry - ✔✔B, C, D How many ausculatory sites are there on the posterior thorax? - ✔✔ 9

when performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is a. an expected finding in a patient with a barrel chest b. seen in patient with kyphosis c. indicative pectus excavatum d. a normal finding in a healthy adult - ✔✔D what is the correct technique for auscultating breath sounds? a. listen to atleast one full respiration in each location b. use the bell of the stethoscope to compare breath sounds side to side c. if pt is modest, listen to sounds over his or her clothing or hospital gown d. listen as pt inhales, and go to the next site during exhalation - ✔✔A Where is the point of maximal impulse palpated in an adult? a. 5th intercostal space, mid-clavicular line b. 5th intercostal space, left sternal border c. 4th intercostal space, mid-clavicular line d. 4th intercostal space, left mid-clavicular line - ✔✔A which technique is used to auscultate the carotid arteries? a. ask the client to take a breath and hold it briefly while you listen with the bell of the stethoscope b. ask the client to take a breath, exhale and hold it briefly while you listen with the bell of the stothoscope c. ask the client to take a breath and hold it briefly while you listen with the diaphragm of the stethoscope d. ask the client to take a breath, exhale and hold it briefly while you listen with the diaphragm of the stothoscope - ✔✔B which heart sound is associated with heart failure? a. S b. systolic murmur

c. S d. diastolic murmur - ✔✔A when obtaining subjective information related to the heart, what information will the nurse obtain? (select all that apply) a. chest pain b. shortness of breath c. fatigue d. edema e. cardiac risk factors f. heart rate and rhythm - ✔✔A, B, C, D, E Where is the apex of the heart located in an infant? a. the fourth, left intercostal space b. the fifth, left intercostal space c. the 6th, left intercostal space d. the fourth, right intercostal space - ✔✔A what is the proper patient position that is used for assessment of jugular veins? A. supine, with head of the bed at 30 - 45 degree elevation B. supine with head of the bed flat C. right side lying position to assess the left jugular vein D. supine with head of the bed at 90 degree elevation - ✔✔A second right interspace - ✔✔aortic valve area second left interspace - ✔✔pulmonic valve area left sternal border, 5th intercostal space - ✔✔tricuspid valve area

fifth interspace, left midclavicular line - ✔✔mitral valve area Which of the following are modifiable risk factors for MI (select all that apply) a. gender b. diabetes c. obesity d. age e. abnormal lipids f. hypertension g. smoking - ✔✔B, C, E, F, G what technique will the nurse use to palpate the carotid arteries? a. use firm pressure to palpate carotid arteries one at a time b. palpate one carotid artery at a time with gental pressure c. palpate both carotid arteries at the same time to compare the two sides d. palpate each carotid artery in the upper part of the neck - ✔✔B when ausculating the heart, the nurse will listen for the following: select all that apply a. listen for extra heart sounds b. listen for murmurs c. identify S1 and S d. note the rate and rhythm e. listen for carotid bruit f. listen for wheezes and rhonchi - ✔✔A, B, C, D Where will the nurse palpate the dorsalis pedis pulse? a. lateral to and parallel with extension tendon of the great toe b. lateral to the medial tendon c. just below the inguinal ligament d. between the malleolus and achilles tendon - ✔✔A

How is a normal force peripheral pulse documented? - ✔✔2+ Arterial ischemic ulcer - ✔✔ulcer on the toe with well defined edges, pale base and no drainage Peripheral artery disease - ✔✔deep muscle pain with walking that is relieved by rest Venous stasis ulcer - ✔✔Shallow ulcer with irregular borders and coupious drainage Venous stasis (insuficiency) - ✔✔Aching pain in legs that is worse at the end of the day, prolonged standing or sitting Where will the nurse palpate the posterior tibial pulse? a. in the groove between the medial maleolus and the achilles tendon b. Just lateral to and parallel with the extensor tendon of the big toe c. in the groove between external maleolus and the achilles tendon d. just medial to and parallel with extensor tendon of the big toe - ✔✔A Inspection of the lower extremities include: (select all that apply) a. venous pattern b. ankle-biracial index c. skin color and condition d. hair distribution e. force of pedal pulses - ✔✔A, C, D The doppler ultrasonic stethoscope is used to a. assess pitting edema b. rate the force of a peripheral pulse c. assess lower extremity skin condition d. detect a weak pulse - ✔✔D

What is the most likely etiology of unilateral upper extremity non pitting brawny edema? a. lymphedema b. arterial ischemic disease c. venous insufficiency d. deep vein thrombosis - ✔✔A When obtaining subjective data regarding the peripheral vascular system the following information will be obtained: (select all that apply) a. Lymph node enlargement b. skin changes on arms or legs c. swelling in arms and/or legs d. leg pain or cramps e. irregular pulse - ✔✔A, B, C, D how will the nurse document very deep pitting, indentation lasts a long time when the skin over the tibia is firmly pressed? a. 4+ pitting edema b. severe, non pitting edema c. brawny edema d. deep pitting edema - ✔✔A what does upper extremity capillary refill time of greater than 1 or 2 seconds indicate? a. vasoconstriction or decreased cardiac output b. systolic hypertension c. decreased force of ulnar pulses d. elevated body temperature - ✔✔A It is normal to see the pulsations of the aorta under the skin in the epigastric area, particularly in a thin patient. a. true

b. false - ✔✔A what is included in the inspection of the abdomen (select all that apply). a. bowel sounds b. umbilicus c. contour of abdomen d. skin characteristics e. pulsations or movements f. subjective data g. symmetry of abdomen - ✔✔B, C, D, E, G Which structures are located in the right lower quadrant of the abdomen? a. appendix, right ovary and tube, and right ureter b. liver, gall bladder, duodenum, and right kidney c. sigmoid colon, aorta, and bladder d. stomach, spleen, and descending colon - ✔✔B describe the technique for auscultating the abdominal aorta a. place the diaphragm firmly on the skin halfway between the umbilicus and the groin on the right and left sides. b. place the bell of the stethoscope lightly on the skin at the midline, 2 inches below the umbilicus. c. place the diaphragm of the stethoscope firmly on the skin about 2 inches superior to the umbilicus d. place the bell of the stethoscope lightly on the skin about 2 inches superior to the umbilicus - ✔✔D Which of the following etilogies of hypoactive bowel sounds? a. late bowel obstruction b. diarrhea c. following abdominal surgery d. peritonitis - ✔✔A, C, D

select the etiology of hyperactive bowel sounds. (select all that apply) a. diarrhea b. increased gastric motility c. peritonitis d. paralytic ileus e. gastroenteritis f. laxative use - ✔✔A, B, E, F what procedure is used to auscultate bowel sounds? a. hold the bell of the stethoscope lightly against the skin after inspection b. hold the bell of the stethoscope lightly against the skin after palpation c. hold the diaphragm of the stethoscope lightly against the skin after inspection d. hold the diaphragm of the stethoscope lightly against the skin after palpation - ✔✔D what procedure will be used to perform light palpation of the abdomen? a. with the first 4 fingers close together, depress the skin about 1 cm, make a gentle rotary motion b. place two hands on top of each other and use the top hand to push down. c. starting to the right of the umbilicus drag the fingers clockwise to each location around the abdomen d. push down 5-8 cm with the first 4 fingers, make a gentle rotary motion - ✔✔A Identify etilogies of everted umbilicus a. ascites b. distended bowel loops c. underlying mass d. pregnancy - ✔✔A, B, C, D how will the nurse document the contour of a distended abdomen a. rounded b. scaphoid c. flat

d. protuberant - ✔✔D