Download NUR 210 Final Exam | 100% Correct Answers | Verified | Latest 2024 Version and more Exams Nursing in PDF only on Docsity!
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 - โโC 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. - โโD 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. - โโA 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 - โโD 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 - โโD 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. - โโA 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 - โโA 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. - โโA which technique will the nurse use to begin a physical exam? A. inspection b. palpation c. percusion d. auscultation - โโA
yellow or green sputum - โโbacterial infection rust colored sputum - โโTB or pneumococcal pneumonia pink frothy sputum - โโpulmonary 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 - โโC 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 - โโC 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 - โโB, C, D How many ausculatory sites are there on the posterior thorax? - โโ 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 - โโD 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 - โโA 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 - โโA 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 - โโB which heart sound is associated with heart failure? a. S b. systolic murmur
fifth interspace, left midclavicular line - โโmitral 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 - โโB, 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 - โโB 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 - โโA, 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 - โโA
How is a normal force peripheral pulse documented? - โโ2+ Arterial ischemic ulcer - โโulcer on the toe with well defined edges, pale base and no drainage Peripheral artery disease - โโdeep muscle pain with walking that is relieved by rest Venous stasis ulcer - โโShallow ulcer with irregular borders and coupious drainage Venous stasis (insuficiency) - โโAching 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 - โโA 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 - โโA, 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 - โโD
b. false - โโA 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 - โโB, 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 - โโB 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 - โโD Which of the following etilogies of hypoactive bowel sounds? a. late bowel obstruction b. diarrhea c. following abdominal surgery d. peritonitis - โโA, 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 - โโA, 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 - โโD 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 - โโA Identify etilogies of everted umbilicus a. ascites b. distended bowel loops c. underlying mass d. pregnancy - โโA, B, C, D how will the nurse document the contour of a distended abdomen a. rounded b. scaphoid c. flat
