COMPREHENSIVE ANSWER DIGEST
◉The nurse listens to Mrs. Sullen's lungs and notes a hissing sound
or musical sound. The nurse documents this as:
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular. Answer: A. Wheezes
Wheezes are indicated by continuous, lengthy, musical; heard during
inspiration or expiration. Rhonchi are usually coarse breath sounds.
Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds
are low pitch, soft intensity on expiration.
◉Becky is on NPO since midnight as preparation for blood test.
Adreno-cortical response is activated. Which of the following is an
expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
, D. Decreased urine output. Answer: D. Decreased urine output
Adreno-cortical response involves release of aldosterone that leads
to retention of sodium and water. This results to decreased urine
output.
◉When performing an abdominal examination, the patient should
be in a supine position with the head of the bed at what position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree. Answer: D. 0 degree
The patient should be positioned with the head of the bed
completely flattened to perform an abdominal examination. If the
head of the bed is elevated, the abdominal muscles and organs can
be bunched up, altering the findings.
◉Which of the following is inappropriate nursing action when
administering NGT feeding?
A. Place the feeding 20 inches above the point of insertion of NGT
B. Introduce the feeding slowly
C. Instill 60ml of water into the NGT after feeding