The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower
lobes when auscultating a client's lungs. How
... [Show More] should this finding be recorded?
A. Inspiratory wheezes in both lungs
B. Crackles in the right and left lower lobes
C. Abdominal lung sounds in the bases of both lungs
D. Pleural friction rub in the right and left lower lobes - B
Fine crackles are short, high pitched sounds heard just before the end of inspiration that are the result
of rapid equalization of pressure when collapsed alveoli or terminal bronchioles suddenly snap open.
Wheezing (A) is a continuous high pitched squeaking or musical sound caused by rapid vibration of
bronchial walls that are first evident on expiration and may be audible. Although (C) describes an
adventitious lung sound, the documentation is vague. (D) is a creaking or grating sound from roughened,
inflamed surfaces of the pleura rubbing together heard during inspiration, expiration, and with no
change during coughing.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering
more of the iris than the right eyelid. Which description should the nurse use to document this finding?
A. Ptosis on the left eyelid
B. A nystagmus on the left
C. Astigmatism on the right
D. Exophthalmos on the right - A
Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may
result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid, rhythmic
movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased visual acuity. (D) is a
term used to describe a protrusion of the eyeballs that occurs with hyperthyroidism
A client's family asks why their mother with heart failure needs a pulmonary artery catheter now that
she is in the ICU. What information should the nurse include in the explanation to the family?
A. A central monitoring system reduces the risk of complications undetected by observation
B. A pulmonary artery catheter measures central pressure for monitoring fluid replacement
C. Pulmonary artery catheters allow for early detection of lung problems
D. The healthcare provider should explain the many reasons for its use. - B
Pulmonary artery catheters are used to measure central pressures and fluid balance. Even though all
clients in the ICU require close monitoring, they do not all need a PA catheter (A). PA lines do not detect
pulmonary problems (C). (D) avoids the family's question.
Several hours after surgical repair of an abdominal aortic aneurysm, the client develops left flank pain.
The nurse determines the client's urinary output is 20 mL/hr for the past 2 hours. The nurse should
conclude that these findings support which complication?
A. Infection
B. Hypovolemia
C. Intestinal ischemia
D. Renal artery embolization - D
Postoperative complications of surgical repair of AAA are related to the location of resection, graft, or
stent placement along the abdominal aorta. Embolization of a fragment of thrombus or plaque from the
aorta into a renal artery can compromise blood flow in one of the renal arteries, resulting in renal
ischemia that precipitates unilateral flank pain. Intraoperative blood loss or rupture of the aorta
anastomosis can cause acute renal failure related to hypovolemia (B), which involves both kidneys and
causing bilateral flank pain. (A) and (C) are not associated with these symptoms
The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency
and stress incontinence. She also reports difficulty emptying her bladder. These complaints are most
likely due to which condition?
A. Cystocele
B. Bladder infection
C. Pyelonephritis
D. Irritable bladder - A
This constellation of signs in a postmenopausal woman are characteristic of cystocele. These symptoms
are not characteristic of (B), (C), or (D)
A male client who has never smoked by has had COPD is now being assessed for cancer of the lung. The
nurse knows that he is most likely to develop which type of lung cancer?
A. Adenocarcinoma
B. Oat-cell carcinoma
C. Malignant melanoma
D. Squamous cell carcinoma - A
Adenocarcinoma is the only lung cancer not related to cigarette smoking. It has been found to be
directly related to lung scarring and fibrosis from preexisting pulmonary disease such as TB or COPD.
Both (B) and (D) are malignant lung cancers related to cigarette smoking. (C) is a skin cancer and is
related to sunlight, not to lung problems
Muscular Dystrophy is characterized by which pathophysiological condition?
A. Stressed induced tremor and trembling
B. Cardiac damage
C. Seizure activity
D. Skeletal muscle degeneration - D
Skeletal muscle degeneration is a classic symptom of muscular dystrophy. Tremors and trembling (A) of
hands, particularly when stressed are symptoms of Parkinson's. Cardiac damage (B) and seizures (C) are
not exclusive to muscular dystrophy
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a
cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What is
the best response for the nurse to provide?
A. Provide a more rapid induction of anesthesia
B. Decrease the risk of bradycardia during surgery
C. Induce relaxation before induction of anesthesia
D. Minimize the amount of analgesia needed postoperatively - B
Atropine may be prescribed to increase the automaticity of the SA node and prevent a dangerous
reduction in HR during surgical anesthesia. (A), (C), and (D) do not address the therapeutic action of
atropine use perioperatively
What information should the nurse include in a teaching plan about the onset of menopause?
A. Smoking
B. Oophorectomy and histerectomy
C. Early menarche
D. Cardiac disease
E. Genetic influence
F. Chemotherapy exposure - A, B, C, E, and F
Menopausal symptoms are related to the cessation of ovarian function. Factors influencing the onset of
menopause include smoking, genetic influences, early menarche, surgical removal, and exposure to
chemotherapy agents and radiation. Cardiovascular disease (D) is unrelated
A patient with aortic valve stenosis develops heart failure. Which pathophysiological finding occurs in
the myocardial cells as a result of the increased cardiac workload?
A. Increase in size
B. Decrease in length
C. Increase in number
D. Decrease in excitability - A
Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart
by increasing the afterload which requires an increase in the force of contraction to pump blood out of
the heart. Myocardial hypertrophy results because the cells increase in surface area or size by increasing
the amount of contractile proteins, but the quantitiy (C) of fibers remain constant. As myocardial
hypertrophy progresses, the heart becomes ineffective as a pump because the ventricular wall cannot
develop enough tension to cause effective contraction (B) which causes myocardial irritability (D) due to
hypoxia
Physical examination of a comatose patient reveals decorticate posturing. Which statement is accurate
regarding this client's status based upon this finding?
A. A cerebral infectious process is causing the posturing
B. Severe dysfunction of the cerebral cortex has occurred
C. There is a probably dysfunction of the midbrain
D. The client is exhibiting signs of a brain tumor - B
Decorticate posturing (adduction of arms and shoulders, flexion of arms on chest with wrists flexed and
hands fisted and extension and adduction of extremities) is seen with severe dysfunction of the cerebral
cortex. (A) is a characteristic of meningitis. (C) is characterized by decerebrate posturing (rigid extension
and pronation of arms and legs). A client with (D) may exhibit decorticate posturing, depending on the
position of the tumor and the condition of the client. [Show Less]