NSG3160 III Practice

When assessing a patient’s lungs, what should the nurse recall about the left lung? a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? (9) a. Between the scapulae b. Third intercostal space, MCL c. Over the lower lobes, posterior side d. Fifth intercostal space, midaxillary line (MAL)

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another? (12) a. Side-to-side comparison b. Top-to-bottom comparison c. Posterior-to-anterior comparison d. Interspace-by-interspace comparison

20. When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

32. A 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? a. Fever, dry nonproductive cough, and diminished breath sounds b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

41. What is the sac that surrounds and protects the heart is called? a. Myocardium b. Pericardium c. Endocardium d. Pleural space

42. The direction of blood flow through the heart is best described by which of these? a. Vena cava  right atrium  right ventricle  lungs  pulmonary artery  left atrium  left ventricle b. Right atrium  right ventricle  pulmonary artery  lungs  pulmonary vein  left atrium  left ventricle c. Aorta  right atrium  right ventricle  lungs  pulmonary vein  left atrium  left ventricle  vena cava d. Right atrium  right ventricle  pulmonary vein  lungs  pulmonary artery  left atrium  left ventricle

48. The 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. What does this finding indicate? a. Decreased fluid volume b. Increased cardiac output c. Narrowing of jugular veins d. Elevated pressure r/t heart failure

55. During 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. What does this finding indicate? a. Valvular disorder b. Blood flow turbulence c. Fluid volume overload d. Ventricular hypertrophy

61. What is the best description of the S1 heart sound? a. Indicates the beginning of diastole. b. Coincides with the carotid artery pulse. c. Louder than the S2 at the base of the heart. d. Is caused by the closure of the semilunar valves.

84. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

88. The nurse is teaching a review class on the lymphatic system. Which statement by a class participant indicates correct understanding of the material? a. “Lymph flow is propelled by the contraction of the heart.” b. “The flow of lymph is slow, compared with that of the blood.” c. “One of the functions of the lymph is to absorb lipids from the biliary tract.” d. “Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.”

94. A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed “a sore” on the outer aspect of the right ankle. What do these findings suggest? a. Pain r/t lymphatic abnormalities b. Problems r/t venous insufficiency c. Problems r/t arterial insufficiency d. Pain r/t musculoskeletal abnormalities

96. The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.