NUR 325 - EXAM 2
1. What is the examination sequence when conducting a complete
abdominal assessment?
a. Inspection, Percussion, Palpation, Auscultation
b. Auscultation, Inspection, Percussion, Palpation
c. Inspection, Auscultation, Percussion, Palpation
d. Auscultation, Inspection, Palpation, Percussion
c. Inspection, Auscultation, Percussion, Palpation
2. The contour of the abdomen is observed during the inspection
portion of the assessment. It is evaluated for distension,
asymmetry, abnormal pulsations, and protuberances. A small,
lateral scar located in the right, lower quadrant of a patient may
be inspected and could help the nurse in identifying what
information about the patient's health history?
a. Incontinence
b. Jaundice
c. Possible hernia
d. Previous appendectomy
d. Previous appendectomy
3. The nurse is conducting an abdominal assessment on a patient
who has been complaining of recent abdominal pain and
recurring infections. During the palpation portion of the
assessment, the nurse notices a palpable organ while feeling
upward towards the costal margin of the abdomen, beyond the
left costal margin. What might the nurse be feeling in this region?
a. An enlarged liver
b. The liver
,c. An enlarged spleen
d. The spleen
c. An enlarged spleen
4. While assessing the patient's abdominal system in the
percussion phase of the evaluation, the nurse notes scattered
dullness in the lower quadrants. What may these sounds be
indicating?
a. Fecal matter in the colon
b. Percussed area contains excessive air
c. The patient has appendicitis
d. There is fluid filling the liver
a. Fecal matter in the colon
5. Which of the following is a possible cause of a firm abdomen?
(Select all that apply.)
a. Overeating
b. An abcess
c. Appendicitis
d. Developed abdomen muscles
e. Constipation
f. Bowel obstruction
g. Diarrhea
a. Overeating
b. An abcess
c. Appendicitis
e. Constipation
f. Bowel obstruction
the nurse teaches a pt who has chronic bronchitis about a new
prescription for combined fluticasone and salmeterol (Dry
Powder Inhaler). which pt action indicates to the nurse that
teaching about med administration has been successful?
,the pt should inhale the med rapidly
the home health nurse is visiting a pt with chronic obstructive
pulmonary disease (COPD). which nursing action is appropriate
to implement for the pt who has an impaired breathing pattern
due to anxiety?
pursed-lip breathing techniques assist in prolonged expiratory phase
and decrease air trapping
the nurse interviews a pt with a new diagnosis of chronic
obstructive pulmonary disease (COPD). which info is specific in
confirming a diagnosis of chronic bronchitis?
diagnosis is based on a history of having a productive cough for 3
months for at least 2 consecutive years; pt. stated that it happened
every winter
the nurse is admitting a pt diagnosed with an acute exacerbation
of chronic obstructive pulmonary disease (COPD) how should the
nurse determine the appropriate O2 flow rate?
maintain the pulse oximetry level of 90% or greater; best way to
determine is by monitoring pts oxygenation; O2 = 90% = adequate
blood O2 levels without danger of suppressing drive to breathe
which info will the nurse include in the teaching plan for a pt
newly diagnosed with asthma?
tremors are an expected side effect of rapid acting bronchodilators
(SABAs)
the nurse is teaching a student about Homan's sign. which
teaching will promote safe practice by the student?
provoking Homan's sing may increase a client's risk for pulmonary
embolism; may cause a clot to be expelled from veins and result in a
pulmonary embolism
, a nurse is teaching a pt about the urinary system in which order
will the nurse present the structures, following the flow of urine?
kidneys, ureters, bladder, urethra
a nurse is caring for an 8-year-old client who is embarrassed
about urinating in bed at night. which intervention should the
nurse suggest to best reduce the frequency of this occurrence?
limit fluid intake 2 hours before bedtime (and limiting caffeinated
beverages)
a nurse is caring for an older adult pt who has a urinary tract
infection. which of the following manifestations should the nurse
identify as a finding specifically associated with this client?
acute confusion; may be a symptom of infection (specifically UTI) in
the elderly population
1. A patient has been facing consecutive gas exchange impairment
due to unmanaged asthma. Pronounced issues with ventilation
can cause a buildup of acid that will most likely present itself
through what condition?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
d. Respiratory acidosis
2. A 30 year-old patient is suffering from 2 fractured ribs
following a motor vehicle accident. In addition to the pain
experienced from injury, the patient is also experiencing an
impairment of gas exchange most likely to do what?
a. Inadequate perfusion
b. Ineffective ventilation
1. What is the examination sequence when conducting a complete
abdominal assessment?
a. Inspection, Percussion, Palpation, Auscultation
b. Auscultation, Inspection, Percussion, Palpation
c. Inspection, Auscultation, Percussion, Palpation
d. Auscultation, Inspection, Palpation, Percussion
c. Inspection, Auscultation, Percussion, Palpation
2. The contour of the abdomen is observed during the inspection
portion of the assessment. It is evaluated for distension,
asymmetry, abnormal pulsations, and protuberances. A small,
lateral scar located in the right, lower quadrant of a patient may
be inspected and could help the nurse in identifying what
information about the patient's health history?
a. Incontinence
b. Jaundice
c. Possible hernia
d. Previous appendectomy
d. Previous appendectomy
3. The nurse is conducting an abdominal assessment on a patient
who has been complaining of recent abdominal pain and
recurring infections. During the palpation portion of the
assessment, the nurse notices a palpable organ while feeling
upward towards the costal margin of the abdomen, beyond the
left costal margin. What might the nurse be feeling in this region?
a. An enlarged liver
b. The liver
,c. An enlarged spleen
d. The spleen
c. An enlarged spleen
4. While assessing the patient's abdominal system in the
percussion phase of the evaluation, the nurse notes scattered
dullness in the lower quadrants. What may these sounds be
indicating?
a. Fecal matter in the colon
b. Percussed area contains excessive air
c. The patient has appendicitis
d. There is fluid filling the liver
a. Fecal matter in the colon
5. Which of the following is a possible cause of a firm abdomen?
(Select all that apply.)
a. Overeating
b. An abcess
c. Appendicitis
d. Developed abdomen muscles
e. Constipation
f. Bowel obstruction
g. Diarrhea
a. Overeating
b. An abcess
c. Appendicitis
e. Constipation
f. Bowel obstruction
the nurse teaches a pt who has chronic bronchitis about a new
prescription for combined fluticasone and salmeterol (Dry
Powder Inhaler). which pt action indicates to the nurse that
teaching about med administration has been successful?
,the pt should inhale the med rapidly
the home health nurse is visiting a pt with chronic obstructive
pulmonary disease (COPD). which nursing action is appropriate
to implement for the pt who has an impaired breathing pattern
due to anxiety?
pursed-lip breathing techniques assist in prolonged expiratory phase
and decrease air trapping
the nurse interviews a pt with a new diagnosis of chronic
obstructive pulmonary disease (COPD). which info is specific in
confirming a diagnosis of chronic bronchitis?
diagnosis is based on a history of having a productive cough for 3
months for at least 2 consecutive years; pt. stated that it happened
every winter
the nurse is admitting a pt diagnosed with an acute exacerbation
of chronic obstructive pulmonary disease (COPD) how should the
nurse determine the appropriate O2 flow rate?
maintain the pulse oximetry level of 90% or greater; best way to
determine is by monitoring pts oxygenation; O2 = 90% = adequate
blood O2 levels without danger of suppressing drive to breathe
which info will the nurse include in the teaching plan for a pt
newly diagnosed with asthma?
tremors are an expected side effect of rapid acting bronchodilators
(SABAs)
the nurse is teaching a student about Homan's sign. which
teaching will promote safe practice by the student?
provoking Homan's sing may increase a client's risk for pulmonary
embolism; may cause a clot to be expelled from veins and result in a
pulmonary embolism
, a nurse is teaching a pt about the urinary system in which order
will the nurse present the structures, following the flow of urine?
kidneys, ureters, bladder, urethra
a nurse is caring for an 8-year-old client who is embarrassed
about urinating in bed at night. which intervention should the
nurse suggest to best reduce the frequency of this occurrence?
limit fluid intake 2 hours before bedtime (and limiting caffeinated
beverages)
a nurse is caring for an older adult pt who has a urinary tract
infection. which of the following manifestations should the nurse
identify as a finding specifically associated with this client?
acute confusion; may be a symptom of infection (specifically UTI) in
the elderly population
1. A patient has been facing consecutive gas exchange impairment
due to unmanaged asthma. Pronounced issues with ventilation
can cause a buildup of acid that will most likely present itself
through what condition?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
d. Respiratory acidosis
2. A 30 year-old patient is suffering from 2 fractured ribs
following a motor vehicle accident. In addition to the pain
experienced from injury, the patient is also experiencing an
impairment of gas exchange most likely to do what?
a. Inadequate perfusion
b. Ineffective ventilation
