Question

11. During as assessment of a healthy adult , where would a nurse expect to observe the apical impulse? A. Forth left intercostal space to the sternal border B. Third left intercostal space at the midclavicular line C. Fifth left intercostal space at the sternal border D. Fifth left intercostal space at the midclavicular line

12. Diaphragmatic excursion should be equal bilaterally and measure about: A. 3-5 CM B. 3-4 CM C. 2-3 CM D. 4-5 CM

13. A nurse has heard decreased breath sounds in a clients left lower lobe in preparing to check for egophony and knows abnormality is: A. The client saying “ee” will be heard as “ay” in the left lower lobe B. The client saying “99” will be louder and clearer in the left lower lobe C. The client saying “99” will be louder and clearer in al lung fields D. The nurse will not be able to hear the patient say or whisper “99” or say “ee”

14. A nurse should anticipate hearing which breathing pattern when listening to breath sounds over a bronchovesicular site? A. Equal inspiration and expiration B. Long expiration and short inspiration C. short inspiration and long expiration D. 2 short inspiration and 1 short expiration

15. A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and documents that the client has which of the fallowing respiratory alternations? A. apneustic respirations B. kussmaul respirations C. Cheyne-stokes respirations D. stridor

16. A client reports difficulty sleeping and states “I’ll be sleeping and then I wake up and feel like I can’t catch my breath”. The nurses best answer is: A. “when was your last echocardiogram” B. “do you have any problems with your heart” C. “do you have any problems with your heart” D. “its probably because the weather has been so hot lately”

17. During a physical examination, the nurse observes a 1cm lesion on the client’s chest. The lesion is raised, multi colored and ------- with? A. gyrate lesion B. maculopapular skin rash C. melanoma D. wheals

18. Which of the fallowing is true about the respiratory system? A. the second rib is connected at the level of the sternal angle B. the left lobe is divided into three lobes C. the first ten pairs of ribs connected directly to the sternum D. each lobe is divided into bronchi

19. During a cardiac assessment of a client experiencing chest pain the nurse finds the fallowing: jugular vein pulsations 4cm above, 130 bpm, bilateral ankle edema, difficulty breathing when supine, an S3 heart sound and capillary refill of 4 seconds. These findings are: A. fluid and electrolyte imbalance B. atrial- septial defect C. peripheral vascular disease D. heart failure

20. A nurse is preforming a cardiac assessment and auscultates an S4 heart sound. The nurse should recognize that this is mostly: A. right bundle branch block B. mitral valve stenosis C. pulmonic valve insufficiency D. younger than 30

Answer 1

11). ANSWER- D

the apical pulse is found at the fifth intercostal space at the the left midclavicular line

12) ANSWER -C

The difference for it is 2-3cm

13) ANSWER -A

On doing egophony in patient with a altered lung condition , the patient is made to say "eee" but the patient hears as "aa".

14) ANSWER D

The inspiratory phase is 2 times more than the expiratory phase so it lasts longer, its ratio is also 2:1.

15) ANSWER- C

Cheyne stokes breathing is generally characterised by alternating pattern of hyperventilation and apnea in sleep.

16) ANSWER A

17) ANSWER C

The other options are not correct because

Gyrate lesions are of diameter more than 5cm

Maculopapular skin rash is red and itchy.

Wheals are also red .

18)ANSWER A

The second rib is connected to the sternum directly at the sternal angle.

Other options wrong because

The left lobe is divided into 2 lobes.

The first 7 ribs are attached directly to the sternum.

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