N391 Summer Exam 2 391-900 Pierre - Adelphi University
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Free N391 Summer Exam 2 391-900 Pierre - Adelphi University Questions
A nursing instructor observes a student assessing a client's neck and jugular veins. Which actions demonstrate correct assessment technique? Select all that apply.
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Use tangential lighting to help visualize jugular venous pulsations.
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Position the client with the head of the bed elevated 30-45 degrees.
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Inspect the jugular veins with the client lying completely flat, even without symptoms.
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Ask the client to turn the head slightly away from the side being assessed.
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Palpate the jugular vein to determine the strength of the pulse.
Explanation
Correct Answer: (A, B, D) Using tangential lighting helps cast subtle shadows that make jugular venous pulsations easier to visualize. Positioning the client with the head of the bed elevated 30-45 degrees is the standard position for assessing jugular venous pressure and pulsations. Asking the client to turn the head slightly away from the side being assessed allows better visualization and access to the jugular vein.
Why the other options are incorrect:
C. Inspect the jugular veins with the client lying completely flat, even without symptoms. Lying completely flat is not the standard position for jugular vein assessment; the head of the bed should typically be elevated to 30-45 degrees for accurate evaluation.
E. Palpate the jugular vein to determine the strength of the pulse. The jugular vein should be inspected visually, not palpated, since it is a low-pressure system; the carotid artery, not the jugular vein, is palpated to assess pulse strength.
A nurse is assessing her postoperative patient and notes a respiratory rate of 28 breaths per minute, restlessness, and an oxygen saturation of 89% on room air. Which of the following best explains the significance of the tachypnea in relation to the hypoxia?
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A respiratory rate of 28 is only a concern if accompanied by adventitious sounds.
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Tachypnea indicates the patient is progressing toward respiratory acidosis.
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The increased respiratory rate compensates for hypoxia by attempting to improve oxygenation.
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Tachypnea is expected after surgery and indicates the need for analgesia.
Explanation
Correct Answer: (C) The increased respiratory rate compensates for hypoxia by attempting to improve oxygenation. The body responds to low oxygen saturation by increasing the respiratory rate in an attempt to bring in more oxygen and improve gas exchange. This tachypnea, combined with restlessness and a low oxygen saturation of 89%, indicates the patient is hypoxic and requires prompt intervention.
Why the other options are incorrect:
A. A respiratory rate of 28 is only a concern if accompanied by adventitious sounds. A respiratory rate of 28 with hypoxia and restlessness is concerning on its own, regardless of whether adventitious sounds are present.
B. Tachypnea indicates the patient is progressing toward respiratory acidosis. Tachypnea typically leads to increased carbon dioxide elimination, which would more likely cause respiratory alkalosis rather than respiratory acidosis.
D. Tachypnea is expected after surgery and indicates the need for analgesia. While pain can contribute to increased respiratory rate, the combination of hypoxia and restlessness in this scenario points to a more serious oxygenation issue rather than simply a need for pain management.
The nurse is assessing clients who report nausea and vomiting. For each assessment finding, identify the potential etiology most associated with the finding. Each finding may be associated with only one etiology.
Sudden vomiting with severe headache and neurological changes.
Fecal-smelling emesis (vomit) with abdominal distention.
Coffee-ground emesis (vomit).
Vomiting with diarrhea and abdominal cramping.
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GI Bleeding.
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Bowel Obstruction.
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Infection/Gastroenteritis.
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Increased Intracranial Pressure.
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GI Bleeding.
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Bowel Obstruction.
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Infection/Gastroenteritis.
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Increased Intracranial Pressure.
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GI Bleeding.
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Bowel Obstruction.
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Infection/Gastroenteritis.
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Increased Intracranial Pressure.
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GI Bleeding.
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Bowel Obstruction.
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Infection/Gastroenteritis.
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Increased Intracranial Pressure.
Explanation
Correct Matches: Increased Intracranial Pressure, Bowel Obstruction, GI Bleeding, Infection/Gastroenteritis. Sudden vomiting accompanied by a severe headache and neurological changes is a classic presentation of increased intracranial pressure, often resulting from projectile vomiting due to pressure on the brainstem's vomiting center. Fecal-smelling emesis with abdominal distention indicates bowel obstruction, as blocked intestinal contents back up and take on a fecal odor due to bacterial overgrowth. Coffee-ground emesis reflects GI bleeding, with the characteristic dark, grainy appearance resulting from blood that has been partially digested by stomach acid. Vomiting accompanied by diarrhea and abdominal cramping is characteristic of infection or gastroenteritis, reflecting an inflammatory response of the GI tract to a pathogen.
The nurse is assessing three clients with shortness of breath. For each assessment finding, select the condition most commonly associated with the finding.
Expiratory wheezing with prolonged expiration. A. Asthma. B. COPD. C. Heart Failure.
Barrel-shaped chest with diminished breath sounds. A. Asthma. B. COPD. C. Heart Failure.
Bilateral crackles with orthopnea and peripheral edema. A. Asthma. B. COPD. C. Heart Failure.
- Asthma
- COPD
- Heart Failure
Explanation
Correct Matches: Asthma, COPD, Heart Failure. Expiratory wheezing with prolonged expiration is characteristic of asthma, reflecting bronchospasm and airway narrowing that makes it harder to exhale air. A barrel-shaped chest with diminished breath sounds is a classic finding in COPD, resulting from chronic hyperinflation and air trapping that flattens the diaphragm and increases the anterior-posterior chest diameter. Bilateral crackles with orthopnea and peripheral edema are hallmark findings of heart failure, reflecting fluid accumulation in the lungs and systemic venous congestion due to the heart's reduced pumping ability.
The nurse is preparing to assess bowel sounds during an abdominal examination. Select all that apply.
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If no bowel sounds are heard, listen for 5 minutes before documenting them as absent.
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Begin listening in the right lower quadrant.
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Auscultate the abdomen before palpation.
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Use the bell of the stethoscope.
Explanation
Correct Answer: (A, B, C) The nurse should listen for a full 5 minutes in each quadrant before documenting bowel sounds as absent, since bowel sounds can be intermittent. Auscultation typically begins in the right lower quadrant because bowel sounds are most reliably heard near the ileocecal valve. Auscultation should always be performed before palpation during an abdominal exam, since palpation and percussion can artificially stimulate bowel motility and alter the sounds heard.
Why the other options are incorrect:
D. Use the bell of the stethoscope. Bowel sounds are best assessed using the diaphragm of the stethoscope, not the bell, which is used for detecting low-pitched sounds such as vascular bruits.
An adult client has come into the walk-in clinic with a two-day history of stool that is "black and sticky." Which of the following should the nurse consider as a potential etiology/cause for this change in stool color and consistency? Select all that apply.
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The patient may have taken an over-the-counter medication containing bismuth subsalicylate.
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The patient may have a gastrointestinal bleed.
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The client may be taking oral iron supplements.
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The patient may have possible vitamin B12 deficiency.
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The patient may have added too much fiber to their diet.
Explanation
Correct Answer: (A, B, C) Bismuth subsalicylate, found in medications like Pepto-Bismol, is well known to cause black stools as a harmless side effect. A gastrointestinal bleed, particularly from the upper GI tract, causes melena, which presents as black, tarry, sticky stool due to the digestion of blood. Oral iron supplements are also a common cause of black stools due to the way iron is metabolized in the digestive tract.
Why the other options are incorrect:
D. The patient may have possible vitamin B12 deficiency. Vitamin B12 deficiency does not cause changes in stool color and is not associated with black, sticky stools.
E. The patient may have added too much fiber to their diet. Increased fiber intake affects stool bulk and frequency but does not cause black or sticky stool changes.
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse may attribute what assessment finding to age-related changes?
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Asymmetrical chest expansion.
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Inaudible posterior lung sounds.
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Slight kyphosis.
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Audible wheeze.
Explanation
Correct Answer: (C) Slight kyphosis. Slight kyphosis, an increased curvature of the thoracic spine, is a common and expected age-related change due to changes in bone density, intervertebral disc thinning, and postural muscle changes that occur with normal aging.
Why the other options are incorrect:
A. Asymmetrical chest expansion. Asymmetrical chest expansion is an abnormal finding that suggests an underlying pathology, such as pneumothorax or atelectasis, rather than a normal age-related change.
B. Inaudible posterior lung sounds. Absent or inaudible lung sounds are abnormal and indicate a potential problem, such as pleural effusion or pneumothorax, not a normal aging change.
D. Audible wheeze. Wheezing is an abnormal adventitious lung sound associated with airway narrowing, such as in asthma or COPD, and is not a normal finding related to aging.
The nurse is planning on auscultating a 75-year-old female client's carotid arteries for bruits. The nurse should plan to:
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Ask the client to hold her breath.
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Ask the client to take several deep breaths in and out through an open mouth.
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Place the diaphragm of the stethoscope over the artery.
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Palpate the arteries before auscultation.
Explanation
Correct Answer: (A) Ask the client to hold her breath. Asking the client to briefly hold her breath eliminates tracheal and breath sounds that could interfere with hearing a carotid bruit, allowing for a clearer auscultation of turbulent blood flow through the artery.
Why the other options are incorrect:
B. Ask the client to take several deep breaths in and out through an open mouth. Deep breathing would introduce extraneous breath sounds that could mask a subtle bruit, making auscultation less accurate.
C. Place the diaphragm of the stethoscope over the artery. Carotid bruits are low-pitched sounds best detected using the bell of the stethoscope, not the diaphragm.
D. Palpate the arteries before auscultation. Palpating the carotid arteries can compress them and potentially reduce cerebral blood flow; auscultation should be performed with light palpation only after or without heavy pressure, and bilateral simultaneous palpation should always be avoided.
During cardiac auscultation, the nurse hears a murmur. Which statement best describes the significance of this finding?
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Blood flow through the heart has stopped briefly.
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The heart valves are closing normally during the cardiac cycle.
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Blood is flowing turbulently through the heart or a heart valve.
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The client has developed an irregular heart rhythm.
Explanation
Correct Answer: (C) Blood is flowing turbulently through the heart or a heart valve. A murmur is an extra or abnormal heart sound caused by turbulent blood flow through the heart chambers or valves, often due to valve dysfunction, structural abnormalities, or increased blood flow velocity.
Why the other options are incorrect:
A. Blood flow through the heart has stopped briefly. A murmur does not indicate a cessation of blood flow; rather, it reflects abnormal or turbulent flow patterns.
B. The heart valves are closing normally during the cardiac cycle. Normal valve closure produces the standard heart sounds (S1 and S2), not a murmur, which is an abnormal additional sound.
D. The client has developed an irregular heart rhythm. An irregular rhythm is identified through pulse or rhythm assessment, not specifically through the presence of a murmur, which relates to blood flow turbulence rather than timing irregularities.
The nurse is performing an abdominal assessment on a client who reports abdominal pain. Complete the sentence by selecting the correct option from each drop-down list.
The nurse should (1) the abdomen before performing deep palpation because (2). (1)
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First.
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Last.
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Only.
Explanation
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