Chapter 08: Health Assessment

Multiple Choice

1. The nurse admits the patient with mild chest pain from the emergency department. Which should the nurse implement first to gain patient cooperation during a physical assessment?

a. Explain the procedure and its purpose.

b. Perform assessment in stages over the day.

c. Complete assessment within 3–5 minutes.

d. Assess painful areas before nontender areas.

ANS: A

First and foremost, the nurse should explain the procedure and its purpose. The patient is more likely to cooperate during a physical assessment if he or she knows what to expect and what the purpose of the procedure is. The nurse explains how the information is used to plan individualized nursing care. The nurse completes the assessment in as few stages as possible because he or she needs the assessment data to plan care. The nurse will assess painful and tender areas last.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Provide a warm heating pad. b. Collaborate with the health care provider. c. Assess the patient’s oxygen saturation. d. Check for restricted venous return.

2. The nurse assesses a patient with light skin and observes normally shaped nail beds exhibiting pallor and a slight bluish color. Which would the nurse implement first?

ANS: C

Nail beds in a patient with light skin are a view of the patient’s capillary bed at the periphery. Pallor and a bluish color in the capillary bed indicate inadequate oxygenation because oxygenated blood is dark red resulting in pink nail beds. The nurse would assess the oxygenation more thoroughly and intervene if needed. A heating pad is not warranted. The nurse will collaborate with the provider, but needs more data first. Since this is a problem in the arterial blood flow, checking venous return is not indicated.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. States name, age, and date but not location. b. Is lethargic; responds logically to questions. c. Responds verbally, but words are unintelligible. d. Responds to questions spontaneously; is alert and oriented.

3. The nurse is performing a neurological assessment. Which patient behaviors demonstrate a level of consciousness within normal limits?

ANS: D

The patient who responds to questions spontaneously and is alert and oriented exhibits neurological findings that are within normal limits. The patient is conscious, responds to the environment, and has congruent thought processes. The patient who does not know the location is disoriented to place. Lethargy is not a normal finding despite correct responses. Unintelligible speech is abnormal.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. At least every 4 hours b. As often as it is needed c. When the patient requests it d. At the rate set by agency policy

4. How often should the nurse perform a general assessment of the patient?

ANS: B

The nurse performs a general assessment at the beginning of the shift and as often as needed afterward; however, the nurse frequently performs a focused assessment to make clinical judgments and problem solve. Every 4 hours is time consuming unless indicated by patient condition. Patients do not determine when to perform an assessment, but the nurse is responsive to patient concerns and resolves the problem to the patient’s satisfaction. Agency policy sets the minimum standard for patients at different levels of acuity, but the nurse always uses judgment to determine when to assess the patient.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. The toes are pink bilaterally. b. The cast is warm at the ankle. c. Paresthesia is present in the left foot. d. The cast is snug at the knee.

5. The nurse is assessing a patient with a cast extending from just below the left knee to the toes. Which assessment contains a desirable patient outcome?

ANS: A

Bilateral pink toes indicate adequate oxygenation to the periphery and support the outcome, “Patient has pink and warm toes bilaterally while wearing cast.” This also implies that the cast fits properly without areas of constriction. An area of warmth on a cast potentially indicates an infection. Paresthesia indicates nerve compression or irritation; when this occurs with a cast in place on the affected extremity, it usually indicates swelling of the extremity, potentially leading to impaired perfusion. A tight cast potentially restricts blood flow and compresses nerves, leading to tissue damage and paresthesias.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Tumor b. Wheal c. Macule

6. The patient has an irregular, elevated, localized area of edema on the left forearm. Which term should the nurse use when documenting?

ANS: B

An irregular, elevated, localized area of edema is a wheal. The nurse documents the approximate size of the wheal. A tumor is a solid mass of abnormal growth larger than 1–2 cm (0.4–0.8 inches). A macule is a flat change in skin pigmentation such as a freckle or petechiae. A vesicle is a round elevation of skin filled with serous fluid.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. The ankle bones are prominent. b. The skin is warm and pink bilaterally. c. The legs ache when in a dependent position. d. The peripheral pulses are absent on both legs.

7. The nurse is concerned with possible impaired peripheral perfusion after performing a patient’s assessment. Which assessment finding about the patient’s lower extremities supports the nurse’s suspicion?

ANS: D

Clinical indicators of impaired perfusion to a lower extremity include absent or diminished pulses, cool and dusky skin, and pain on exertion; if the disease is advanced, the patient potentially has pain at rest. Prominent ankle bones are normal. Warm pink skin is a clinical indicator of adequate tissue oxygenation. Aching in the lower extremities when in the dependent position is characteristic of venous insufficiency.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Rales in the right lower lobe b. No adventitious breath sounds c. Pleural friction rub in the left lung d. Inspiratory wheezing in the upper lobes

8. The nurse is listening to the patient’s lungs. Which information should the nurse use to document normal patient lung sounds?

ANS: B

A clinical indicator of normal lung sounds is a lack of adventitious breath sounds, meaning that the patient does not exhibit crackles, rhonchi, rubs, stridor, or wheezing. Rales are the same as crackles and indicate fluid or atelectasis in the alveoli. Pleural friction rubs are not normal and indicate inflammation of the pleural lining. Wheezing indicates constriction of the airway as heard during an asthma attack.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Takes rapid shallow breaths. b. Breathes with the mouth open. c. Coughs and then takes a deep breath. d. Takes a deep breath and holds it.

9. The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction by the nurse has been effective if the patient breathes in which manner?

ANS: B

The nurse instructs the patient to breathe with the mouth open because this facilitates air movement and amplifies patient lung sounds. In addition, the nurse instructs the patient to take slow deep breaths. Rapid shallow breaths quickly induce hypocarbia, leading to lightheadedness and fatigue, and impair auscultation of breath sounds because the sounds are too faint to assess. Coughing and deep breathing are instructions to facilitate the mobilization of pulmonary secretions. Holding the breath impairs the nurse’s ability to auscultate air movement for a respiratory assessment.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 210 mL b. 390 mL c. 600 mL d. 630 mL

10. A patient has the following intake: a cup of oatmeal, a half cup of ice, 3 ounces of apple juice, and 6 ounces of coffee. What is the total intake the nurse should document on the intake portion?

ANS: B

The oatmeal is not counted because it is not fluid. A half cup of ice = 120 mL because it equals 50% of the measured volume. The juice is 3 ounces = 90 mL, and 6 ounces of coffee = 180 mL. Therefore, the total is 120 + 90 + 180 = 390 mL.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Auscultate apical pulse of a patient with acute angina. b. Take vital signs of a patient who might be discharged. c. Complete lung assessment of a patient with pneumonia. d. Clarify effects of antihypertensive therapy for a patient.

11. Which aspect of obtaining health information can the nurse delegate to nursing assistive personnel (NAP)?

ANS: B

The task of taking vital signs of a patient who may be discharged may be delegated to NAP. Assessing the apical pulse on a patient with acute angina, completing a lung assessment, and evaluating the effects of therapies cannot be delegated to NAP.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Percusses the left ventricular wall. b. Palpates along the left sternal border. c. Directs the patient to lie in a supine position. d. Listens at the fifth intercostal space at the point of maximal impulse (PMI).

12. The nurse is teaching a nursing student the correct technique for assessing an apical pulse. Which method when used by the student demonstrates adequate knowledge?

ANS: D

To locate the apical pulse, the nurse locates the fifth intercostal space on the left midclavicular line; this point should coincide with the patient’s PMI. Evaluation of the heart rarely includes percussion. Palpation along the left sternal border reveals cardiac thrusts and thrills; however, the apical pulse is not proximate to the sternal border. The nurse positions the patient with the head of the bed at 30 degrees for patient comfort and to facilitate cardiac assessment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. The abdomen is auscultated after percussion. b. The nurse instructs the patient to extend the legs. c. The nurse inspects the abdomen before auscultation. d. The assessment begins with palpation, followed by auscultation.

13. The nurse is preparing to assess the patient’s abdomen. Nursing care is appropriate if which maneuver is seen?

ANS: C

For an abdominal assessment, the nurse begins with inspection followed by auscultation to prevent accidental stimulation of movement, potentially leading to inaccurate assessment data. The nurse has the patient bend at the knees to relax the abdominal wall, making abdominal palpation easier. Palpation never precedes auscultation of the abdomen.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Use of an assistive device b. Wearing glasses c. Get-up-and-go test completed in 35 seconds d. Romberg’s test position held for 25 seconds

14. An older adult is being assessed by the nurse. Which finding does the nurse consider abnormal when assessing the patient’s risk for fall?

ANS: C

The get-up-and-go test is an assessment that should be conducted as part of a routine evaluation of older adults. The test detects people at risk for falling. The normal time it takes a person to complete the test is 10–20 seconds, so this is an abnormal result. The Romberg’s reflex is normally negative, meaning that when the patient stands with feet together, arms down at sides, and eyes open (20–30 seconds) or closed (20–30 seconds), there is minimal to no swaying. Using an assistive device or wearing glasses does not put the patient at risk for falling unless they are not using their devices.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Use a Doppler device to locate pulses. b. Massage the feet and ankles twice daily. c. Elevate the legs slightly when in the chair. d. Measure the circumference of the thighs daily.

15. The nurse assesses a patient with arterial occlusive disease in the lower extremities. Which activity by the nurse is most appropriate?

ANS: A

The nurse uses a Doppler device to locate peripheral pulses for a patient with arterial occlusive disease because arteries in this health alteration are often difficult to locate as they slowly narrow and impair oxygenated blood flow. Massaging areas of impaired arterial perfusion are contraindicated because the patient is already at risk for breakdown. The legs of the patient with arterial occlusive disease usually need to be dependent to allow gravity to help pull oxygenated blood to the periphery. Elevating the legs promotes venous return and increases the difficulty of oxygenating the tissue because the vessels need to deliver oxygenated blood through inadequate arteries. Thigh measurement is indicated for thromboembolic events, venous insufficiency, or other disorders that impair venous return.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “You seem reluctant to provide information.” b. “We need complete data to plan nursing care.” c. “It will take a short time to answer all questions.” d. “We need to determine contributors to your pain.”

16. A patient with back pain asks why the nurse needs so many details about health history. What is the most effective response by the nurse?

ANS: B

The nurse explains that comprehensive data facilitate individualized patient care, lower patient risks of injury, and increase patient safety. Determining factors that contribute to the patient’s pain is part of a pain assessment and one of the details that help the nurse plan individualized patient care. Stating that the patient seems reluctant to provide information is placing an interpretation on the motives and may be completely off base if the patient is just trying to understand the process. Commenting that not much time is needed to answer the questions is not responsive to the patient’s question.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Rhonchi b. Pleural friction rub c. Wheezes d. Crackles

17. The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings?

ANS: B

A pleural friction rub is heard over the anterior lateral lung field if the patient is sitting upright. It has a grating quality that is best heard during inspiration. It does not clear with coughing. It indicates inflamed parietal pleura rubbing against visceral pleura. Rhonchi indicate fluid or mucus in larger airways causing turbulence in the airways. Rhonchi can sometimes be cleared by coughing. Wheezes are heard all over the lung fields and indicate a narrowed or obstructed bronchus. Crackles, formerly called rales, are most common in dependent lobes and indicate fluid in the small airways.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Ask the patient about valve replacement surgery. b. Apply 3 L of oxygen via nasal cannula. c. Assess the patient’s blood pressure. d. Explain that this is a normal finding in older adults.

18. The nurse is assessing an older patient and finds the heart rate to be 52 beats per minute and irregular. Suddenly the patient complains of dizziness and “feeling faint.” Which action does the nurse take next?

ANS: C

An irregular heart rate and dizziness are abnormal findings and symptoms, and the nurse immediately checks the blood pressure to obtain more data about cardiac output. The health care provider will be notified immediately for follow-up. An electrocardiogram (ECG) will be ordered along with other studies. History is important, but the current status is the priority. The patient may or may not need oxygen.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. No aortic bruit b. Firm liver edge c. Bowel sounds audible d. Abdomen distended and taut

19. The nurse assesses the patient admitted with constipation. Which assessment finding warrants further investigation?

ANS: D

A distended abdomen that is round and taut is a significant finding for a patient with constipation because it potentially indicates a bowel obstruction and the patient may need emergency care. Absence of aortic bruits, a firm liver edge, and audible bowel sounds are normal findings.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Explore how the patient’s family reacts to the disability. b. Evaluate patient concerns about the problem at this time. c. Determine how the alteration affects the patient’s lifestyle. d. Validate the amount of physical rehabilitation completed.

20. The nurse assesses the patient with altered musculoskeletal function. Which is the best reason supporting the nurse’s motive for asking detailed questions?

ANS: C

Determining how the altered musculoskeletal function affects the patient’s lifestyle is the best reason for the nurse to ask detailed questions. With skillful follow-up questioning, the nurse learns the most comprehensive information about the patient, including family reactions, patient concerns, and rehabilitation issues.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. A history of pallor b. Jaundice c. Cyanosis d. Ecchymosis

21. The nurse observes yellow sclerae while assessing the patient’s eyes. What does the nurse look for to validate this finding?

ANS: B

The nurse concludes that the yellow sclerae are indicators of jaundice, an accumulation of bilirubin in the skin. Jaundice is also seen in the mucus membranes and skin. Pallor is skin without a pink cast. Skin with a bluish or dusky cast is an indicator of cyanosis. Ecchymosis is purplish to yellow green and results from subcutaneous bleeding.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Rhonchi b. Wheezes c. Crackles d. Friction rub

22. The nurse assesses the patient’s lungs to find high-pitched musical sounds on inspiration and expiration. Which description does the nurse use to document the findings?

ANS: B

High-pitched musical breath sounds are wheezes that result from bronchospasm; the smaller the constricted airways, the higher the pitch of the wheeze. Rhonchi are low-pitched rumblings indicative of fluid in larger airways; rhonchi are potentially cleared with coughing. Crackles are higher pitched and sharper sounding than rhonchi, indicating fluid or atelectasis in dependent lobes of the lungs. A friction rub is heard on inspiration and expiration but characteristically is a grating sound. A friction rub is frequently accompanied by pain and fever.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. S3 b. Point of maximal impulse (PMI) c. Murmur d. Visible pulsations

23. The nurse is performing a cardiovascular assessment at the fifth intercostal space at the midclavicular line. What would the nurse be attempting to check?

ANS: B

The nurse expects to find the PMI at the fifth intercostal space at the midclavicular line because this is where the left ventricle is the closest to the chest wall. The nurse follows palpation of the PMI with auscultation of the apical pulse. If the patient’s heart is dilated or hypertrophic, the PMI shifts to the left toward the anterior axillary line. S3 or murmur auscultated near any heart valve is generally abnormal along with visible pulsations (called a lift or heave) coming from the heart.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. 2+ pitting edema b. Mild pitting edema c. 2+ nonpitting edema d. Severe nonpitting edema

24. The nurse documents the patient’s swollen lower extremities and measures the depth of a 4-mm indentation made 1 minute ago. Which is the best description for the nurse to use to describe the patient’s lower extremities?

ANS: A

2+ pitting edema is the best description of a lasting indentation of swollen legs at a depth of 4 mm. Mild and severe are subjective terms open to interpretation. Documentation must include that the edema is pitting because the indentation lingers for at least a minute.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. They are 3 mm in size. b. Both of them are round. c. Absence of convergence. d. They respond to light spontaneously.

25. The nurse assesses the pupils of an older patient. What unexpected finding might the nurse identify about the patient’s pupils?

ANS: C

Convergence of the pupils indicates appropriate accommodation. A lack of convergence would indicate an abnormality to be investigated further. A 3-mm size, roundness, and responsiveness to light are expected findings of an eye assessment, indicating that the oculomotor cranial nerve (III) is intact.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Upper spine bent slightly b. Spine in straight alignment c. Slumping to nondominant side d. Dominant side of patient favored

26. The nurse assesses the adult patient’s spine. Which expected finding does the nurse identify about the patient’s alignment and posture?

ANS: B

The anterior posterior alignment of the spine should be a straight line from the skull to the sacrum. The other findings would be unexpected. An excessive thoracic curvature is kyphosis, which is common with vertebral compression fractures of the thoracic spine. Slumping to the nondominant side and favoring the dominant side are abnormal findings, indicating muscular weakness or abnormal spine alignment.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Regular borders b. Larger than 6 mm c. Symmetrical borders d. Reddened coloration

27. The nurse assesses a possible melanoma on the patient’s skin. Which characteristic does the lesion have that is consistent with a melanoma?

ANS: B

Melanomas are usually larger than 6 mm in diameter. In addition, melanomas are usually asymmetrical lesions with irregular borders and blue, black, or variegated coloring.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Ecchymosis resulting from low hemoglobin b. Cyanosis due to hypoxia c. Petechiae which are seen only in the mouth d. Erythema because of over-exertion

28. The nurse assesses the oral mucosa for pathological color changes. Which finding would the nurse see in the patient’s mouth, and what does it indicate?

ANS: B

The nurse can assess cyanosis in the mouth, which is especially helpful for assessing dark-skinned people. Ecchymosis is not usually seen in the mouth and would not be due to low hemoglobin. Petechiae are usually invisible in patients’ mouths. It is possib le to observe erythema in the mouth, keeping in mind that the tongue can be beefy red in color.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Pallor b. Jaundice c. Cyanosis d. Erythema

29. The patient has iron deficiency anemia. What sign causes the nurse to intervene as a priority?

ANS: C

The nurse’s priority is to prevent cyanosis because it is a late sign of hypoxia. The patient is most likely pale already, so the nurse cannot prevent pallor. Because the patient has a narrow margin between adequate oxygenation and hypoxia, the nurse’s priority is to prevent hypoxia until the patient’s iron stores and erythrocyte counts increase to restore pinkness to the skin.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Oral thermometer b. Dorsum of the hand c. Tympanic thermometer d. Thumb and index finger

30. The nurse is assessing the temperature of the lower legs. Which method should the nurse use to best assess the patient’s skin temperature subjectively?

ANS: B

To evaluate the patient’s skin temperature according to the nurse’s opinion, the nurse uses the dorsal aspect of the hand because this skin is thin and more sensitive to temperature changes. An oral or tympanic thermometer evaluates temperature objectively and provides information about the temperature of the body, not the extremities. Thumb and index finger are not used to evaluate the skin temperature subjectively because these are the most frequently used fingers and the skin is likely to be thicker and less sensitive to slight temperature fluctuations.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Wheals b. Nodules c. Macules d. Vesicles

31. The school nurse alerts parents to observe for chickenpox. Which clinical indicator does the nurse instruct the parents to observe for chickenpox?

ANS: D

When chickenpox first erupts, the lesions are small, fluid-filled skin elevations called vesicles Wheals are irregular elevated areas found with mosquito bites. Nodules are an elevated but solid mass. The vesicles of chickenpox change to pustules as the illness wanes.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Prone b. Side lying c. High-Fowler’s d. Dorsal recumbent

32. The patient is being assessed for a possible respiratory problem. In which position should the patient be placed to facilitate chest expansion during a thoracic assessment?

ANS: C

The nurse helps the patient assume high-Fowler’s position to facilitate lung expansion during a thoracic assessment. The prone position would place the patient face down on the bed, making it impossible to see the chest expansion. The dorsal recumbent position is used in an abdominal exam. Side lying is a position used by the nurse to assess the posterior thorax of a patient who cannot cooperate with the examination.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Percussion of the lateral thorax b. Palpation of the anterior thorax c. Measurement of the respiratory rate d. Inspection of the posterior thorax

33. The nurse is preparing to begin the thoracic assessment of a patient. What is the initial step of the thoracic assessment?

ANS: D

The nurse begins a thoracic assessment by inspecting the posterior thorax to identify any factors that can impair chest expansion or cause respiratory distress. Lateral percussion is not used in a respiratory assessment because the biggest lung fields are across the patient’s back. Palpation of the anterior thorax follows assessment of the posterior thorax. Measuring the respiratory rate follows the posterior thoracic inspection.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Observation of respiratory effort b. Percussion over air-filled regions c. Auscultation of thorax symmetrically d. Palpation of chest inspiratory movement

34. The nurse begins to assess the patient’s respiratory system. Which assessment by the nurse best determines the patient’s diaphragmatic excursion?

ANS: D

The nurse palpates the patient’s thoracic movement by placing hands on each side of the spine with thumbs adjacent to one another and instructs the patient to breathe deeply. On inspiration the nurse observes or measures the respiratory excursion, a reflection of the patient’s inspiratory volume. Observing respiratory effort reveals data on the work of breathing. The nurse percusses over areas of suspected fluid accumulation to determine the size of the fluid from consolidation from pneumonia or a pleural effusion. The nurse symmetrically auscultates the thorax to compare bilateral breath sounds.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. At the costovertebral angle b. Over the costochondral junction c. At Erb’s point d. On the left side at the second intercostal space

35. The nurse is preparing to auscultate the pulmonic area. At which site should the nurse place the stethoscope?

ANS: D

The nurse locates the pulmonic area at the second intercostal space, on the left side at the midclavicular line. This location is useful for assessing the pulmonic valve. The costovertebral angle is at the inferior aspect of the sternum. The costochondral junction is the point where a bony rib meets the cartilage connecting the rib to the sternum. The third intercostal space, Erb’s point, is a useless location for cardiac or respiratory assessments.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Assesses the painful areas first. b. Auscultates each quadrant for 5 minutes. c. Palpates lightly to locate painful and tender areas. d. Positions the patient with the arms behind the head.

36. The nurse is performing an abdominal assessment. Which action indicates proper technique?

ANS: C

The nurse lightly palpates the abdomen to determine any painful or tender areas so the patient does not worry about the nurse aggravating the pain and the nurse can conduct a comprehensive abdominal assessment. Assessing painful areas first can terminate the assessment if the assessment exacerbates patient pain. Auscultating for 5 minutes is excessive for routine assessment. The nurse positions the patient with arms at the side and knees flexed to facilitate relaxation of the abdominal wall.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Place the patient in high-Fowler’s position. b. Obtain a stat portable chest x-ray film. c. Notify the health care provider immediately. d. Complete a full respiratory assessment.

37. The nurse admitted a patient with clear lungs and 2 days later has rhonchi in the left lung. Which should the nurse implement next?

ANS: D

Because this is a new finding for the patient, the nurse facilitates suitable patient care by obtaining a comprehensive patient assessment to communicate to the health care provider. There are no data indicating that the patient is in respiratory distress requiring a STAT film. The nurse should notify the health care provider promptly, but he or she needs to finish the complete respiratory examination first as long as the patient is not in acute distress.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Edema b. Warm skin c. Palpable pulses d. Pain with exercise

38. The nurse assesses peripheral perfusion. Which does the nurse find in a patient with arterial insufficiency?

ANS: D

N

The patient with arterial insufficiency usually reports pain with exercise because the blood flow through arteries in the lower extremities is insufficient to meet tissue oxygen demands. The tissue reverts to anaerobic metabolism with increased accumulation of carbon dioxide and lactic acid, precipitating pain in the tissues. The pain often improves with rest and dependent positioning. Edema is consistent with venous insufficiency. Warm skin and palpable pulses are consistent with adequate arterial perfusion of tissues.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Measure the muscle size. b. Perform range of motion. c. Apply pressure against resistance. d. Observe the patient’s gait and transfers.

39. The nurse is performing a neuromuscular assessment. Which method should the nurse use to evaluate muscle strength?

ANS: C

The nurse applies pressure against the patient’s resistance to measure muscle strength to make the subjective evaluation safe. Muscle size is not part of the assessment for strength. Range of motion indicates flexibility of joints. Observing a patient’s gait is a valuable measure of the patient’s muscle strength but is not used initially because it increases the risk of patient injury.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation