89%(413)366 out of 413 people found this document helpful
This preview shows page 7 - 9 out of 9 pages.
A nurse assesses a client's capillary refill and finds it to be about 4 seconds. Which of thefollowing should the nurse do next?Question 85 out of 5 pointsAssessment of a client's radial pulse reveals that it is normal and obliterates withmoderate pressure. The nurse documents the pulse amplitude as which of the following?
Question 95 out of 5 pointsOn auscultation of valvular sounds over the precordium, what area is auscultated at thethird to fifth intercostal space at the left sternal border?Question 105 out of 5 pointsOn auscultation of valvular sounds over the precordium, what area is auscultated at thesecond or third intercostal space at the left sternal border?Question 110 out of 5 pointsIn many situations nurses elect to take blood pressure in the legs (ankle) , often becausethe arms have IVs or other lines. How does the ankle blood pressure value compare withthe brachial blood pressure?Question 120 out of 5 pointsWhat would the nurse document when listening to breath sounds and hearing a low, softsound with short expiration and long inspiration?Question 135 out of 5 pointsThe nurse is assessing the various lobes of the client's lungs. To gather accurate data, thenurse must assess which lobe anteriorly, since this lobe does not extend to the posteriorchest?Question 145 out of 5 pointsWhen auscultating the left carotid artery, the nurse notes a swishing sound. What wouldthis suggest?Question 155 out of 5 pointsWhat would the nurse suspect when a cardiac client complains of not sleeping well andhaving to get up frequently at night to urinate?Question 165 out of 5 pointsThe nurse is listening to the precordium, and identifies a heart murmur so loud it can be
heard with the stethoscope not in full contact with the chest. What rating would thismurmur merit?Question 175 out of 5 pointsA client is noted to be leaning forward with arms supporting body weight as the nurseenters the exam room. For what disease process should the nurse assess fully?Question 180 out of 5 pointsKyphosis is common in older adult resulting from loss of lung resiliency and loss ofskeletal muscleQuestion 195 out of 5 pointsThe provider notes that a patient is able to breathe only when propped up by twopillows. The term for this is :Question 205 out of 5 pointsThe nurse is analyzing the data from the assessment of a client's heart and neck vessels. Theclient's second heart sound (S2) corresponds with what event in the cardiac cycle?Saturday, November 21, 2015 5:11:14 PM CST