Exam 3 Part 1

1. 1A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

   1. AInflammation of the pleura
   2. BMuscular spasms in the larger airways
   3. CSudden reinflation of groups of alveoli
   4. DHigh velocity airflow through an obstructed airway
2. 2A nurse reviews the chest examination reports of four clients with respiratory disorders. Which client’s findings indicate atelectasis?
   

   1. AClient A: palpatio- decreased chest wall movement; percussion-hyper-resonance; auscultation-wheezes
   2. BClient B: palpation-increased vibrations over chest wall above effusion; percussion-dull; auscultation-diminished or absent over effusion
   3. CClient C: palpation-decreased fremitus; percussion-dull over affected areas; auscultation-crackles
   4. DClient D: palpation-increased fremitus over affected area; percussion-dull over affected area; auscultation-bronchial sounds
3. 3While caring for different clients with respiratory problems, the nurse assesses the different alterations in the breathing pattern. Which client’s assessment findings indicate Cheyne-Stokes respiration?

   1. AClient 1: breathing pattern-regular and abnormally slow at 11 breaths/min
   2. BClient 2: breathing pattern-regular but abnormally rapid at 25 breaths/min
   3. CClient 3: breathing pattern-irregular, alternating apnea and hyperventilation at 12 breaths/min
   4. DClient 4: breathing pattern-abnormally shallow for 2 breaths followed by apnea at 30 breaths/min
4. 4The manubriosternal angle is:
   

   1. AThe articulation of the manubrium and the body of the sternum
   2. BA hollow, U-shaped depression just above the sternum
   3. CAlso known as the breastbone
   4. DA term synonymous with costochondral junction
5. 5Select the correct description of the left lung.
   

   1. ANarrower than the right lung with three lobes
   2. BNarrower than the right lung with two lobes
   3. CWider than the right lung with two lobes
   4. DShorter than the right lung with three lobes
6. 6You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as:
   

   1. AContinuous throughout the day
   2. BProductive cough for at least 3 months of the year for 2 consecutive years
   3. COccurring in the afternoon or evening because of exposure to irritants at work
   4. DOccurring in the early morning
7. 7Which of the following assessments best confirms symmetric chest expansion?
   

   1. APlacing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs
   2. BInspection of the shape and configuration of the chest wall
   3. CPlacing the palmar surface of the fingers of one hand against the chest and having the person repeat the words “ninety-nine”
   4. DPercussion of the posterior chest
8. 8Absence of diaphragmatic excursion occurs with:
   

   1. Aasthma
   2. BAn unusually thick chest wall
   3. CPleural effusion or atelectasis of the lower lobes
   4. DAge-related changes in the chest wall
9. 9You are auscultating breath sounds on a patient. Which of the following best describes how to proceed?
   

   1. AHold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field.
   2. BHold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons.
   3. CListen from the apices to the bases of each lung field using the bell of the stethoscope.
   4. DSelect the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side
10. 10 Select the best description of bronchovesicular breath sounds.

    1. AHigh-pitched, of longer duration on inspiration than expiration
    2. BModerate-pitched, inspiration equal to expiration
    3. CLow-pitched, inspiration greater than expiration
    4. DRustling sound, like the wind in the trees

11. 11After examining a patient, you make the following notation: increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with:
    

    1. Abronchitis
    2. Basthma
    3. Cpleural effusion
    4. DLobar pneumonia
12. 12On examining a patient’s nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with:
    

    1. AAcute respiratory distress syndrome
    2. BNormal findings for the nails
    3. CCongenital heart disease and COPD
    4. DAtelectasis
13. 13 On auscultating a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient reports pain with breathing. These findings are consistent with:
    

    1. AFine crackles
    2. Bwheezes
    3. CAtelectatic crackles
    4. DPleural friction rub
14. 14 To use the technique of egophony, ask the patient to:
    

    1. ATake several deep breaths and then hold for 5 seconds.
    2. BSay “eeeeee” each time the stethoscope is moved.
    3. CRepeat the phrase “ninety-nine” each time the stethoscope is moved.
    4. DWhisper a phrase as auscultation is performed.
15. 15When examining for tactile fremitus, it is important to:
    

    1. AAsk the patient to breathe quickly.
    2. BAsk the patient to cough.
    3. CPalpate the chest symmetrically.
    4. DUse the bell of the stethoscope.
16. 16Pulse oximetry measures:
    

    1. AArterial oxygen saturation of hemoglobin
    2. BVenous oxygen saturation of hemoglobin
    3. CCombined saturation of arterial and venous blood
    4. DCarboxyhemoglobin levels
17. 17A pleural friction rub is best detected by:
    

    1. Aobservation
    2. Bpalpation
    3. Causcultation
    4. Dpercussion
18. 18A patient has a barrel-shaped chest, characterized by:
    

    1. AEqual anteroposterior transverse diameter and ribs being horizontal
    2. BAnteroposterior transverse diameter of 1:2 and an elliptic shape
    3. CAnteroposterior transverse diameter of 2 : 1 and ribs being elevated
    4. DAnteroposterior transverse diameter of 3 : 7 and ribs sloping back
19. 19Rests on the diaphragm

    1. Abase
    2. Blateral left
    3. Clateral right
    4. Dposterior apex
20. 20C7

    1. Aposterior apex
    2. Bapex
    3. Cbase
    4. Dlateral left
21. 21Sixth rib, midclavicular line

    1. Alateral left
    2. Blateral right
    3. Cposterior apex
    4. Dapex
22. 22Fifth intercostal

    1. Alateral right
    2. Bposterior apex
    3. Capex
    4. Dbase
23. 233 to 4 cm above the inner third of the clavicles
    

    1. Aapex
    2. Bbase
    3. Clateral left
    4. Dlateral right
24. 24Anteroposterior = transverse diameter

    1. Abarrel chest
    2. BPectus excavatum
    3. CPectus carinatum
    4. Dscoliosis
25. 25Exaggerated posterior curvature of thoracic spine

    1. AKyphosis
    2. Bnormal chest
    3. Cbarrel chest
    4. DPectus excavatum
26. 26Lateral S-shaped curvature of the thoracic and lumbar spines

    1. Ascoliosis
    2. BKyphosis
    3. Cnormal chest
    4. Dbarrel chest
27. 27Sunken sternum and adjacent cartilages

    1. APectus excavatum
    2. BPectus carinatum
    3. Cscoliosis
    4. DKyphosis
28. 28Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2

    1. Anormal chest
    2. Bbarrel chest
    3. CPectus excavatum
    4. DPectus carinatum
29. 29Forward protrusion of the sternum with ribs sloping back at either side
    

    1. APectus carinatum
    2. Bscholiosis
    3. CKyphosis
    4. Dnormal chest
30. 30The precordium is:
    

    1. AA synonym for the mediastinum
    2. BThe area on the chest where the apical impulse is felt
    3. CThe area on the anterior chest overlying the heart and great vessels
    4. DA synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart
31. 31Select the best description of the tricuspid valve.
    

    1. ALeft semilunar valve
    2. BRight atrioventricular valve
    3. CLeft atrioventricular valve
    4. DRight semilunar valve
32. 32The function of the pulmonic valve is to:
    

    1. ADivide the left atrium and left ventricle
    2. BGuard the opening between the right atrium and right ventricle
    3. CProtect the orifice between the right ventricle and the pulmonary artery
    4. DGuard the entrance to the aorta from the left ventricle
33. 33Atrial systole occurs:
    

    1. ADuring ventricular systole
    2. BDuring ventricular diastole
    3. CConcurrently with ventricular systole
    4. DIndependently of ventricular function
34. 34The second heart sound is the result of:
    

    1. AOpening of the mitral and tricuspid valves
    2. BClosing of the mitral and tricuspid valves
    3. COpening of the aortic and pulmonic valves
    4. DClosing of the aortic and pulmonic valves
35. 35 The examiner is has estimated the jugular venous pressure. Identify the finding that is abnormal.
    

    1. APatient elevated to 30 degrees, internal jugular vein pulsation at 1 cm above sternal angle
    2. BPatient elevated to 30 degrees, internal jugular vein pulsation at 2 cm above sternal angle
    3. CPatient elevated to 40 degrees, internal jugular vein pulsation at 1 cm above sternal angle
    4. DPatient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle
36. 36 The examiner is palpating the apical impulse. Which is a normal-sized impulse?
    

    1. ALess than 1 cm
    2. BApproximately 1 × 2 cm
    3. C3 cm
    4. DVaries depending on the size of the person
37. 37The nurse auscultates the pulmonic valve area in which region?
    

    1. ASecond right interspace
    2. BSecond left interspace
    3. CLeft lower sternal border
    4. DFifth interspace, left midclavicular line
38. 38Which description would differentiate a split S2 from S3?
    

    1. AS3 is lower pitched and is heard at the apex.
    2. BS2 is heard at the left lower sternal border.
    3. CThe timing of S2 varies with respirations.
    4. DS3 is heard at the base; the timing varies with respirations.
39. 39 You auscultate a patient to rule out a pericardial friction rub. Which assessment technique is most appropriate?
    

    1. AListen with the diaphragm, patient sitting up and leaning forward, breath held in expiration.
    2. BListen using the bell with the patient leaning forward.
    3. CListen at the base during normal respiration.
    4. DListen with the diaphragm, patient turned to the left side.
40. 40When auscultating the heart, your first step is to:
    

    1. AIdentify S1 and S2.
    2. BListen for S3 and S4.
    3. CListen for murmurs.
    4. DIdentify all four sounds on the first round.
41. 41 You will hear a split S2 most clearly in which area?
    

    1. Aapical
    2. Bpulmonic
    3. Ctricuspid
    4. Daortic
42. 42The stethoscope bell should be pressed lightly against the skin so that:
    

    1. AChest hair doesn’t simulate crackles
    2. BHigh-pitched sounds can be heard better.
    3. CThe bell does not act as a diaphragm.
    4. DThe bell does not interfere with amplification of heart sounds.
43. 43A murmur is heard after S1 and before S2. This murmur would be classified as:
    

    1. ADiastolic (possibly benign)
    2. BDiastolic (always pathologic)
    3. CSystolic (possibly benign)
    4. DSystolic (always pathologic)
44. 44When assessing the carotid artery, the nurse should palpate:
    

    1. ABilaterally at the same time while standing behind the patient
    2. BMedial to the sternomastoid muscle, one side at a time
    3. CFor a bruit while asking the patient to hold his or her breath briefly
    4. DFor unilateral distention while turning the patient’s head to one side
45. 45S1 is best heard at the _____ of the heart

    1. Aapex
    2. Bbase
    3. Cright side
    4. Dleft side
46. 46S2 is loudest at the _____ of the heart

    1. Aapex
    2. Bbase
    3. Cright side
    4. Dleft side
47. 47S1 coincides with the pulse in the _____ and coincides with the _____ wave if the pt is on an ECG monitor

    1. Acarotid artery, P
    2. Bcarotid artery, R
    3. Caorta, Q
    4. Daorta, S
48. 48Tough, fibrous, double-walled sac that surrounds and protects the heart
    

    1. Apericardium
    2. Batrium
    3. Cpericardial fluid
    4. Dventricle
49. 49Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves
    

    1. Aendocardium
    2. Bmyocardium
    3. Cpericardium
    4. Datrium
50. 50Reservoir for holding blood

    1. Aatrium
    2. Bpericardial fluid
    3. Cventricle
    4. Dendocardium
51. 51Ensures smooth, friction-free movement of the heart muscle

    1. Apericardial fluid
    2. Bventricle
    3. Cendocardium
    4. Dmyocardium
52. 52Muscular pumping chamber

    1. Aventricle
    2. Bendocardium
    3. Cmyocardium
    4. Dpericardium
53. 53Muscular wall of the heart
    

    1. Amyocardium
    2. Bpericardium
    3. Catrium
    4. Dpericardial fluid
54. 54The nurse knows that the proper technique for assessing lungs in an adult patient is that auscultation is performed:
    

    1. Afrom right to left using a “z” pattern.
    2. Bfrom top to bottom using landmarks for accuracy
    3. Cusing the bell of the stethoscope to hear vascular sounds
    4. Dto the anterior chest wall and abdomen to determine diaphragm function
55. 55The nurse is assessing a patient with tactile fremitus. The nurse should suspect that the patient has a(n):
    

    1. Ablocked bronchus
    2. Bmild case of pneumonia
    3. Cadvanced case of pneumonia
    4. Dpleural effusion
56. 56Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

    1. AThe spinous process of C7.
    2. BUsually nonpalpable in most individuals.
    3. COpposite the interior border of the scapula.
    4. DLocated next to the manubrium of the sternum.
57. 57When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

    1. AObserved in patients with kyphosis.
    2. BIndicative of pectus excavatum.
    3. CA normal finding in a healthy adult.
    4. DAn expected finding in a patient with a barrel chest.
58. 58When assessing a patient’s lungs, the nurse recalls that the left lung:

    1. AConsists of two lobes.
    2. BIs divided by the horizontal fissure.
    3. CPrimarily consists of an upper lobe on the posterior chest.
    4. DIs shorter than the right lung because of the underlying stomach.
59. 59Which statement about the apices of the lungs is true? The apices of the lungs:

    1. AAre at the level of the second rib anteriorly.
    2. BExtend 3 to 4 cm above the inner third of the clavicles.
    3. CAre located at the sixth rib anteriorly and the eighth rib laterally.
    4. DRest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).
60. 60During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the:

    1. ACostal angle.
    2. BSternal angle.
    3. CXiphoid process.
    4. DSuprasternal notch.
61. 61During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

    1. AAdventitious sounds and limited chest expansion.
    2. BIncreased tactile fremitus and dull percussion tones.
    3. CMuffled voice sounds and symmetric tactile fremitus.
    4. DAbsent voice sounds and hyperresonant percussion tones.
62. 62The primary muscles of respiration include the:

    1. ADiaphragm and intercostals.
    2. BSternomastoids and scaleni.
    3. CTrapezii and rectus abdominis.
    4. DExternal obliques and pectoralis major.
63. 63A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?

    1. AObtaining a detailed health history of the patient’s allergies and a history of asthma
    2. BTelling the patient to sleep on his or her right side to facilitate ease of respirations
    3. CAssessing for other signs and symptoms of paroxysmal nocturnal dyspnea
    4. DAssuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week
64. 64When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

    1. ABetween the scapulae
    2. BThird intercostal space, MCL
    3. CFifth intercostal space, midaxillary line (MAL)
    4. DOver the lower lobes, posterior side
65. 65The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus:

    1. A“Is caused by moisture in the alveoli.”
    2. B“Indicates that air is present in the subcutaneous tissues.”
    3. C“Is caused by sounds generated from the larynx.”
    4. D“Reflects the blood flow through the pulmonary arteries.”
66. 66During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

    1. AShallow breathing.
    2. BNormal lung tissue.
    3. CDecreased adipose tissue.
    4. DIncreased density of lung tissue.
67. 67The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison.

    1. ASide-to-side
    2. BTop-to-bottom
    3. CPosterior-to-anterior
    4. DInterspace-by-interspace
68. 68When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:

    1. ANormally auscultated over the trachea.
    2. BBronchial breath sounds and normal in that location.
    3. CVesicular breath sounds and normal in that location.
    4. DBronchovesicular breath sounds and normal in that location.
69. 69The nurse is auscultating the chest in an adult. Which technique is correct?

    1. AInstructing the patient to take deep, rapid breaths
    2. BInstructing the patient to breathe in and out through his or her nose
    3. CFirmly holding the diaphragm of the stethoscope against the chest
    4. DLightly holding the bell of the stethoscope against the chest to avoid friction
70. 70The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal:

    1. ADullness.
    2. BTympany.
    3. CResonance.
    4. DHyperresonance.
71. 71During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

    1. AWhen the bronchial tree is obstructed
    2. BWhen adventitious sounds are present
    3. CIn conjunction with whispered pectoriloquy
    4. DIn conditions of consolidation, such as pneumonia
72. 72The nurse knows that a normal finding when assessing the respiratory system of an older adult is:

    1. AIncreased thoracic expansion.
    2. BDecreased mobility of the thorax.
    3. CDecreased anteroposterior diameter.
    4. DBronchovesicular breath sounds throughout the lungs.
73. 73A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had “a runny nose for a week.” When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse’s next action should be to:

    1. AAssure the mother that these signs are normal symptoms of a cold.
    2. BRecognize that these are serious signs, and contact the physician.
    3. CAsk the mother if the infant has had trouble with feedings.
    4. DPerform a complete cardiac assessment because these signs are probably indicative of early heart failure.
74. 74When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

    1. ACrepitus palpated at the costochondral junctions
    2. BNo diaphragmatic excursion as a result of a child’s decreased inspiratory volume
    3. CPresence of bronchovesicular breath sounds in the peripheral lung fields
    4. DIrregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest
75. 75When inspecting the anterior chest of an adult, the nurse should include which assessment?

    1. ADiaphragmatic excursion
    2. BSymmetric chest expansion
    3. CPresence of breath sounds
    4. DShape and configuration of the chest wall
76. 76The nurse knows that auscultation of fine crackles would most likely be noticed in:

    1. AA healthy 5-year-old child.
    2. BA pregnant woman.
    3. CThe immediate newborn period.
    4. DAssociation with a pneumothorax.
77. 77During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

    1. AIn an obese patient
    2. BWhen part of the lung is obstructed or collapsed
    3. CWhen bulging of the intercostal spaces is present
    4. DWhen accessory muscles are used to augment respiratory effort
78. 78During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

    1. AAirway obstruction
    2. BEmphysema
    3. CPulmonary consolidation
    4. DAsthma
79. 79The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:

    1. AMusical in quality.
    2. BUsually caused by a pathologic disease.
    3. CExpected near the major airways.
    4. DSimilar to bronchial sounds except shorter in duration.
80. 80The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

    1. AWheezes
    2. BBronchial sounds
    3. CBronchophony
    4. DWhispered pectoriloquy
81. 81A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?

    1. AUnequal chest expansion
    2. BIncreased tactile fremitus
    3. CAtrophied neck and trapezius muscles
    4. DAnteroposterior-to-transverse diameter ratio of 1:1
82. 82A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

    1. ABronchitis.
    2. BPneumothorax.
    3. CAcute pneumonia.
    4. DAsthmatic attack.
83. 83An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

    1. AAsthma.
    2. BAtelectasis.
    3. CLobar pneumonia.
    4. DHeart failure.
84. 84The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult?

    1. ASevere dyspnea is experienced on exertion, resulting from changes in the lungs.
    2. BRespiratory muscle strength increases to compensate for a decreased vital capacity.
    3. CDecrease in small airway closure occurs, leading to problems with atelectasis.
    4. DLungs are less elastic and distensible, which decreases their ability to collapse and recoil.
85. 85A woman in her 26th week of pregnancy states that she is “not really short of breath” but feels that she is aware of her breathing and the need to breathe. What is the nurse’s best reply?

    1. A“The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.”
    2. B“The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.”
    3. C“What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.”
    4. D“This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother’s body, which results in an increased respiratory rate.”
86. 86A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse’s preliminary analysis, based on this history, is that this patient may be suffering from:

    1. ABronchitis.
    2. BPneumonia.
    3. CTuberculosis.
    4. DPulmonary edema.
87. 87A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?

    1. AShortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema
    2. BRasping cough, thick mucoid sputum, wheezing, and bronchitis
    3. CProductive cough, dyspnea, weight loss, anorexia, and tuberculosis
    4. DFever, dry nonproductive cough, and diminished breath sounds
88. 88A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate:

    1. APneumonia.
    2. BPostnasal drip or sinusitis.
    3. CExposure to irritants at work.
    4. DChronic bronchial irritation from smoking.
89. 89During a morning assessment, the nurse notices that the patient’s sputum is frothy and pink. Which condition could this finding indicate?

    1. ACroup
    2. BTuberculosis
    3. CViral infection
    4. DPulmonary edema
90. 90During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?

    1. AListening to at least one full respiration in each location
    2. BListening as the patient inhales and then going to the next site during exhalation
    3. CInstructing the patient to breathe in and out rapidly while listening to the breath sounds
    4. DIf the patient is modest, listening to sounds over his or her clothing or hospital gown
91. 91A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

    1. AAbsent or decreased breath sounds
    2. BProductive cough with thin, frothy sputum
    3. CChest pain that is worse on deep inspiration and dyspnea
    4. DDiffuse infiltrates with areas of dullness upon percussion
92. 92During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

    1. ATactile fremitus.
    2. BCrepitus.
    3. CFriction rub.
    4. DAdventitious sounds.
93. 93The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

    1. AAtelectatic crackles that do not have a pathologic cause.
    2. BFine crackles and may be a sign of pneumonia.
    3. CVesicular breath sounds.
    4. DFine wheezes.
94. 94A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

    1. ABradypnea
    2. BCheyne-Stokes respirations
    3. CHypoventilation
    4. DChronic obstructive breathing
95. 95A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

    1. AStridor
    2. BFriction rub
    3. CCrackles
    4. DWheezing
96. 96The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

    1. AVoice sounds are faint, muffled, and almost inaudible when the patient whispers “one, two, three” in a very soft voice.
    2. BAs the patient repeatedly says “ninety-nine,” the examiner clearly hears the words “ninety-nine.”
    3. CWhen the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.
    4. DAs the patient says a long “ee-ee-ee” sound, the examiner also hears a long “ee-ee-ee” sound.
    5. EAs the patient says a long “ee-ee-ee” sound, the examiner hears a long “aaaaaa” sound.
97. 97The nurse knows that the proper technique for assessing a patient’s carotid arteries is to:
    

    1. Apalpate on the side of the neck using the diaphragm of the stethoscope
    2. Bauscultate with the bell of the stethoscope at the top of the femur and palpate for bruits
    3. Causcultate with the bell of the stethoscope on the side of the neck, listen for bruits, and palpate for thrills
    4. Dauscultate with the diaphragm of the stethoscope just above the pelvic region
98. 98The school nurse hears an extra heart sound on a 16-year-old male athlete. The nurse believes this is because:
    

    1. Aan extra heart sound in a child or young adult is usually considered a physiological S3 and is considered normal
    2. Bthis patient may have a heart murmur and will need to be checked by a cardiologist
    3. Cthe nurse should assess if the patient has been running because an extra heart sound may be the heart’s reaction to increased activity.
    4. Dthe nurse should determine if heart disease runs in the patient’s family and refer him to his primary care physician
99. 99The sac that surrounds and protects the heart is called the:

    1. APericardium.
    2. BMyocardium.
    3. CEndocardium.
    4. DPleural space.
100. 100The direction of blood flow through the heart is best described by which of these?

     1. AVena cava → right atrium → right ventricle → lungs → pulmonary artery → left atrium → left ventricle
     2. BRight atrium → right ventricle → pulmonary artery → lungs → pulmonary vein → left atrium → left ventricle
     3. CAorta → right atrium → right ventricle → lungs → pulmonary vein → left atrium → left ventricle → vena cava
     4. DRight atrium → right ventricle → pulmonary vein → lungs → pulmonary artery → left atrium → left ventricle
101. 101The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?

     1. AThe atria contract during systole and attempt to push against closed valves.
     2. BContraction of the atria at the beginning of diastole can be felt as a palpitation.
     3. CAtrial kick is the pressure exerted against the atria as the ventricles contract during systole.
     4. DThe atria contract toward the end of diastole and push the remaining blood into the ventricles.
102. 102When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:

     1. AMitral and tricuspid.
     2. BTricuspid and aortic.
     3. CAortic and pulmonic.
     4. DMitral and pulmonic.
103. 103Which of these statements describes the closure of the valves in a normal cardiac cycle?

     1. AThe aortic valve closes slightly before the tricuspid valve.
     2. BThe pulmonic valve closes slightly before the aortic valve.
     3. CThe tricuspid valve closes slightly later than the mitral valve.
     4. DBoth the tricuspid and pulmonic valves close at the same time.
104. 104The component of the conduction system referred to as the pacemaker of the heart is the:

     1. AAtrioventricular (AV) node.
     2. BSinoatrial (SA) node.
     3. CBundle of His.
     4. DBundle branches.
105. 105The electrical stimulus of the cardiac cycle follows which sequence?

     1. AAV node → SA node → bundle of His
     2. BBundle of His → AV node → SA node
     3. CSA node → AV node → bundle of His → bundle branches
     4. DAV node → SA node → bundle of His → bundle branches
106. 106The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

     1. ADecreased fluid volume.
     2. BIncreased cardiac output.
     3. CNarrowing of jugular veins.
     4. DElevated pressure related to heart failure.
107. 107When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?

     1. AThe left ventricle is larger and weighs more than the right ventricle.
     2. BThe circulation of a newborn is identical to that of an adult.
     3. CBlood can flow into the left side of the heart through an opening in the atrial septum.
     4. DThe foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after.
108. 108A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

     1. AThis decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
     2. BBecause of increased cardiac output, the blood pressure should be higher at this time.
     3. CThis change in blood pressure is not an expected finding because it means a decrease in cardiac output.
     4. DThis decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.
109. 109In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age?

     1. AIncrease in resting heart rate
     2. BIncrease in systolic blood pressure
     3. CDecrease in diastolic blood pressure
     4. DIncrease in diastolic blood pressure
110. 110A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. “I’ll be sleeping great, and then I wake up and feel like I can’t get my breath.” The nurse’s best response to this would be:

     1. A“When was your last electrocardiogram?”
     2. B“It’s probably because it’s been so hot at night.”
     3. C“Do you have any history of problems with your heart?”
     4. D“Have you had a recent sinus infection or upper respiratory infection?”
111. 111In assessing a patient’s major risk factors for heart disease, which would the nurse want to include when taking a history?

     1. AFamily history, hypertension, stress, and age
     2. BPersonality type, high cholesterol, diabetes, and smoking
     3. CSmoking, hypertension, obesity, diabetes, and high cholesterol
     4. DAlcohol consumption, obesity, diabetes, stress, and high cholesterol
112. 112The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?

     1. AInfant’s sleeping position
     2. BSibling history of eating disorders
     3. CAmount of background noise when eating
     4. DPresence of dyspnea or diaphoresis when sucking
113. 113In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

     1. APalpate the artery in the upper one third of the neck.
     2. BListen with the bell of the stethoscope to assess for bruits.
     3. CSimultaneously palpate both arteries to compare amplitude.
     4. DInstruct the patient to take slow deep breaths during auscultation.
114. 114During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:

     1. AValvular disorder.
     2. BBlood flow turbulence.
     3. CFluid volume overload.
     4. DVentricular hypertrophy.
115. 115During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):

     1. ANormal heart.
     2. BSystolic murmur.
     3. CEnlargement of the left ventricle.
     4. DEnlargement of the right ventricle.
116. 116During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

     1. AThird left intercostal space at the midclavicular line
     2. BFourth left intercostal space at the sternal border
     3. CFourth left intercostal space at the anterior axillary line
     4. DFifth left intercostal space at the midclavicular line
117. 117The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?

     1. APercussion is a useful tool for outlining the heart’s borders.
     2. BPercussion is easier in patients who are obese.
     3. CStudies show that percussed cardiac borders do not correlate well with the true cardiac border.
     4. DOnly expert health care providers should attempt percussion of the heart.
118. 118The nurse is preparing to auscultate for heart sounds. Which technique is correct?

     1. AListening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas
     2. BListening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex
     3. CListening to the sounds only at the site where the apical pulse is felt to be the strongest
     4. DListening for all possible sounds at a time at each specified area
119. 119While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse’s response?

     1. ATalk with the patient about his intake of caffeine.
     2. BPerform an electrocardiogram after the examination.
     3. CNo further response is needed because sinus arrhythmia can occur normally.
     4. DRefer the patient to a cardiologist for further testing.
120. 120When listening to heart sounds, the nurse knows that the S1:

     1. AIs louder than the S2 at the base of the heart.
     2. BIndicates the beginning of diastole.
     3. CCoincides with the carotid artery pulse.
     4. DIs caused by the closure of the semilunar valves.
121. 121During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?

     1. AHave the patient turn to the left side while the nurse listens with the bell of the stethoscope.
     2. BAsk the patient to hold his or her breath while the nurse listens again.
     3. CNo further assessment is needed because the nurse knows this sound is an S3.
     4. DWatch the patient’s respirations while listening for the effect on the sound.
122. 122Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?

     1. AS3 when sitting up
     2. BPersistent tachycardia above 150 beats per minute
     3. CMurmur at the second left intercostal space when supine
     4. DPalpable apical impulse in the fifth left intercostal space lateral to midclavicular line
123. 123While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?

     1. AS3 is indicative of heart disease in children.
     2. BThese findings can all be normal in a child.
     3. CThese findings are indicative of congenital problems.
     4. DThe venous hum most likely indicates an aneurysm.
124. 124During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:

     1. ARight ventricular hypertrophy.
     2. BIncreased volume and size of the heart as a result of pregnancy.
     3. CDisplacement of the heart from elevation of the diaphragm.
     4. DIncreased blood flow through the internal mammary artery.
125. 125In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

     1. ABell of the stethoscope at the base with the patient leaning forward.
     2. BBell of the stethoscope at the apex with the patient in the left lateral position.
     3. CDiaphragm of the stethoscope in the aortic area with the patient sitting.
     4. DDiaphragm of the stethoscope in the pulmonic area with the patient supine.
126. 126A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient’s history, the nurse knows that this extra heart sound is most likely a(n):

     1. ASplit S1.
     2. BAtrial gallop.
     3. CDiastolic murmur.
     4. DSummation sound.
127. 127The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:

     1. AIncreased cardiac output.
     2. BAnother MI.
     3. CInflammation of the precordium.
     4. DVentricular hypertrophy resulting from muscle damage.
128. 128The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?

     1. ATetralogy of Fallot
     2. BAtrial septal defect
     3. CPatent ductus arteriosus
     4. DVentricular septal defect
129. 129A 30-year-old woman with a history of mitral valve problems states that she has been “very tired.” She has started waking up at night and feels like her “heart is pounding.” During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with:

     1. AHeart failure.
     2. BAortic stenosis.
     3. CPulmonary edema.
     4. DMitral regurgitation.
130. 130During a cardiac assessment on a 38-year-old patient in the hospital for “chest pain,” the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?

     1. AFluid overload
     2. BAtrial septal defect
     3. CMI
     4. DHeart failure
131. 131The nurse knows that normal splitting of the S2 is associated with:

     1. AExpiration.
     2. BInspiration.
     3. CExercise state.
     4. DLow resting heart rate.
132. 132During a cardiovascular assessment, the nurse knows that a thrill is:

     1. AVibration that is palpable.
     2. BPalpated in the right epigastric area.
     3. CAssociated with ventricular hypertrophy.
     4. DMurmur auscultated at the third intercostal space.
133. 133During a cardiovascular assessment, the nurse knows that an S4 heart sound is:

     1. AHeard at the onset of atrial diastole.
     2. BUsually a normal finding in the older adult.
     3. CHeard at the end of ventricular diastole.
     4. DHeard best over the second left intercostal space with the individual sitting upright.
134. 134During an assessment, the nurse notes that the patient’s apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:

     1. ASystemic hypertension.
     2. BPulmonic hypertension.
     3. CPressure overload, as in aortic stenosis.
     4. DVolume overload, as in heart failure.
135. 135When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

     1. AWhile listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it.
     2. BWhile auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations.
     3. CWhile lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
     4. DWhile firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
136. 136The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

     1. ABlacks
     2. BWhites
     3. CAmerican Indians
     4. DHispanics
137. 137The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient’s abdomen, just below the rib cage?

     1. AThe jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working.
     2. BThe jugular veins will remain elevated as long as pressure on the abdomen is maintained.
     3. CAn impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line.
     4. DThe jugular veins will not be detected during this maneuver.
138. 138The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

     1. ANormal for this age.
     2. BLower than expected.
     3. CHigher than expected, probably as a result of crying.
     4. DHigher than expected, reflecting persistent tachycardia.
139. 139The nurse is assessing a patient’s pulses and notices a difference between the patient’s apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit?

     1. A13
     2. B223
     3. C6
     4. D23
140. 140The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply.

     1. AEthnicity
     2. BAbnormal lipids
     3. CSmoking
     4. DGender
     5. EHTN
     6. FDM
     7. GFamily history
141. 141n the diagram, which letter identifies the patent ductus arteriosus?

     

     1. AA
     2. BB
     3. CC
     4. DD
     5. EE
142. 142After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?

     1. AThe diameter of the aorta is enlarged
     2. BThe wall between the right and left ventricles is open.
     3. CIt is a narrowing of the entrance to the pulmonary artery.
     4. DIt is a connection between the pulmonary artery and the aorta
143. 143During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest?

     1. Abase of the heart
     2. Bapex of the heart
     3. Cleft lateral border
     4. Dright lateral border
144. 144A nurse is auscultating a client's heart sounds and hears S1. Which valves is the nurse assessing?

     1. AMitral and tricuspid
     2. BAortic and tricuspid
     3. CMitral and pulmonic
     4. DAortic and pulmonic
145. 145When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?

     1. Aaortic
     2. Bmitral
     3. Cpulmonic
     4. Dtricuspid
146. 146A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client’s cardiac output? Record your answer using a whole number. _____mL/min

     1. A5040
     2. B2
     3. C142
     4. D71
147. 147The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume?

     1. A70 mL
     2. B60 mL
     3. C50 mL
     4. D40 mL
148. 148The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention?

     1. AUpright at 90 degrees
     2. BSupine position
     3. CRaised to 30 degrees
     4. DRaised to 10 degrees
149. 149While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?

     1. AHeredity
     2. BHTN
     3. CSmoking
     4. DDM
150. 150While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?

     1. ARadial and apical pulse
     2. BApical and carotid pulse
     3. CRadial and brachial pulse
     4. DApical and temporal pulse
151. 151While assessing a client, the nurse finds bluish coloration of the skin. The nurse finds that this discoloration is due to cyanosis. Which condition may be suspected?

     1. Aanemia
     2. Bliver disease
     3. Cheart disease
     4. Dautoimmune disease
152. 152A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen?

     1. ATo prevent dyspnea
     2. BTo prevent cyanosis
     3. CTo increase oxygen concentration to heart cells
     4. DTo increase oxygen tension in the circulating blood
153. 153Which landmark is correct for a nurse to use when auscultating the mitral valve?

     1. ALeft fifth intercostal space, midaxillary line
     2. BLeft fifth intercostal space, midclavicular line
     3. CLeft second intercostal space, sternal border
     4. DLeft fifth intercostal space, sternal border
154. 154While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure?

     1. Achild
     2. Bpregnant woman
     3. Colder adult
     4. Dyoung adult
155. 155Which finding is inferred from a grade 4 intensity of heart murmurs?

     1. AThrill is easily palpable
     2. BQuiet and clearly audible thrill
     3. CLoud murmur associated with thrill
     4. DModerately loud murmur without thrill
156. 156A nurse is teaching a client about the normal pathway followed during the cardiac cycle. In which sequence should the nurse list the structures, beginning with the first?

     1. ASA node --> AV node --> bundle branches --> bundle of His --> purkinje fibers
     2. BSA node --> AV node --> bundle of His --> bundle branches --> purkinje fibers
     3. CAV node--> SA node --> bundle branches --> bundle of His--> purkinje fibers
     4. DAV node --> SA node --> purkinje fibers --> bundle of His --> bundle branches
157. 157A nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart effectively?

     1. A
     2. B
     3. C
     4. D
158. 158When assessing an 85-year-old client’s vital signs, the nurse anticipates a number of changes in cardiac output that result from the aging process. Which finding is consistent with a pathologic condition rather than the aging process?

     1. AA pulse rate irregularity
     2. BEqual apical and radial pulse rates
     3. CA pulse rate of 60 beats per minute
     4. DAn apical rate obtainable at the fifth intercostal space and midclavicular line
159. 159A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply.

     1. ADecreased ventricular filling time
     2. BIncreased coronary artery filling
     3. CDecreased cardiac output
     4. DIncreased atrial kick
     5. EIncreased cardiac output
160. 160An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload?

     1. AContour
     2. BOrthopneic
     3. CRecumbent
     4. DTrendelenburg
161. 161The nurse documents the data gathered during the assessment in a client’s medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers?

     1. ARecord subjective information in own words
     2. BForm judgments through written communication
     3. CRecord objective information using accurate terminology
     4. DCompare data from the physical examination with client behavior
162. 162After assessing a dark-skinned client, the nurse concludes that the client has cyanosis. Which assessment color variation helped the nurse reach this conclusion?

     1. AGrey color
     2. BPurple color
     3. CDark red color
     4. DPurple-to-brownish color
163. 163A nurse is obtaining a health history on a client admitted to the hospital with heart failure. Which assessment finding will the nurse expect the client to report?

     1. AFeeling bloated after eating
     2. BTingling in the upper extremities
     3. CNeeding to use three pillows at night to sleep
     4. DSwelling of the ankles that is more apparent in the morning
164. 164The parents of an infant with tetralogy of Fallot ask the nurse to explain what is wrong with their baby’s heart. Before explaining the problem in a way that they will understand, the nurse remembers that tetralogy of Fallot includes what features?

     1. ATricuspid atresia, ventricular septal defect, atrioventricular canal, and coarctation of the aorta
     2. BOverriding of the aorta, aortic stenosis, patent ductus arteriosus, and mitral valve insufficiency
     3. CAtrial septal defect, right ventricular hypertrophy, patent ductus, and mitral valve insufficiency
     4. DRight ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding of the aorta

Description

Health Assessment I Quiz on Exam 3 Part 1, created by Nicole Buda on 21/09/2016.

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Nicole Buda

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Created on 21 Sep 2016 · updated on 8 Mar 2018

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health assessment i

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