NUR306 COMPLETE EAQ BASED FINAL
SET WITH QUESTIONS AND ANSWERS
The nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally declares
with coughing. Which condition would the nurse associate with the sounds?
Parietal pleura, rubbing against visceral pleura
Random sudden reinstallation of groups of alveoli
Turbulence due to muscular spasm and fluid or mucus in the larger airways
High velocity, air flow through a severely narrowed or obstructed airway - ANS-✅Turbulence due to
muscular spasm and fluid or mucus in the larger airways
Rationale:
Loud, low pitched, rumbling course sounds heard over the trachea and bronchi = turbulence caused by
muscular spasm when fluid or mucus is present in the larger airways.
Pleural rub = sound of dry or grading quality, best heard in the lower portion of the anterior lateral long.
Random and sudden reinflation of groups of alveoli = crackling sounds predominantly heard in the left
and right lung bases.
High velocity, air flow through severely narrowed or obstructed airway = wheezing sound heard all over
the lung
When obtaining a health history, from the newly admitted, client who has chronic pain in the right knee,
which pain assessment data, would the nurse include? Select all that apply.
Pain, history, including location, intensity, and quality of pain
Clients purposeful body movement, and arranging the papers on the bedside table
Pain pattern, including precipitating in alleviating factors
Vital signs, such as increase blood pressure and heart rate
The clients family statement about increases in pain with ambulation - ANS-✅Pain, history, including
location, intensity, and quality of pain
Pain pattern, including precipitating, and alleviating factors
Rationale:
The initial pain assessment should include information about the location, quality, intensity, onset,
duration, and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a
secondary assessment related to the initial.
The nurse assesses bilateral plus for peripheral edema well assessing a client with heart failure and
peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
Shift of fluid into the interstitial spaces
Weakening of the cell wall
Increased intravascular compliance
Increased intracellular fluid volume - ANS-✅Shift of fluid into the interstitial spaces
Which client is at risk for heart disease?
Client one - red, face, area of trauma, sacrum, shoulders
Client two - bluish, nail beds, lips, mouth, skin
,Client three - pallor, face, conjunctivae, nail beds, palms of hands
Client four - yellow, orange, sclera, mucous membranes, skin - ANS-✅Client two
Rationale:
These symptoms may be due to an increased amount of deoxygenated, hemoglobin, which may be due
to heart or lung disease. Client one would indicate fever or trauma. Client three would indicate anemia.
Client number four would indicate jaundice or liver disease.
The nurse assesses the length of a client, auscultates soft, crackling, bubbling breath sounds that are
more obvious on inspiration. Which term with the nurse use to document the sounds?
Vesicular
Bronchial
Crackles
Rhonchi - ANS-✅Crackles
Rationale:
Crackles are abnormal breath sounds described as soft, crackling, bubbling, sounds, produced by air,
moving across fluid in the alveoli .
Rhonchi or abnormal breath, sounds heard over the large airways of the lungs, and consist of a low pitch
and are caused by the movement of secretions in the larger airways; they usually clear with coughing
The secular breath sounds are normal they are quiet, soft, and inspiration sounds that are short and
almost silent on expiration and heard over the long periphery.
Bronchioles breath sounds are normal and consist of a full inspiration and expiratory phase with the
expiratory phase, being louder, and are heard over the trachea and large bronchi of the lungs.
During orientation, a registered nurse reviews Contant about the third heart sound S3 with recently
employed nurses. Which participants statement indicates ineffective learning?
S3 is heard in clients with heart failure
S3 is a normal sound in pregnant women
S3 is abnormal and adults over 31 years of age
S3 is normal in children and young adults - ANS-✅S3 is normal in pregnant women
Rationale:
A third heart sound can be heard when the heart attempts to fill an already distended ventricle. This
sound may be common and normal in the last stages of pregnancy, but not in all stages. The sound may
be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. The sound is
normally heard in children and young adults .
Which client's assessment playing correctly yield's effective results?
Ulnar - ulnar side of forearm at the wrist - cardiac arrest one other sites are not palpable
Carotid - along the medial edge of the sternocleidomastoid muscle in the neck - presence of owner
blood flow
Dorsalis pedis - along the top of the foot - status of circulation to the foot
Posterior tibial - above the medial malleolus - status of circulation to the foot - ANS-✅Dorsalis pedis
Rationale:
Owner site is used to assess the status of circulation to the hand and to perform the Allen test. The
carotid site is used to assess in times of physiological shock or cardiac arrest when other sites are not
, palpable. The posterior tibial site is found below, not above, the medial malleolus, and is used to assess
the status of circulation in the foot.
Which step of the nursing process involves the nurse interviewing a client about current health problem
and obtaining the clients vital signs?
Planning
Diagnosis
Assessment
Implementation - ANS-✅Assessment
Which site with the nurse prefer to assess for determining the turgor of an older adult select all that
apply
Back of the neck
Back of the hand
Palm of the hand
On the sternal area
Back of the forearm - ANS-✅On the sternal area, and back of the forearm
Rationale:
The rest of the sites are not reliable or ideal sites for turgor assessment
Which action would the nurse take for a client whose right radio pulse is weak and thready? select all the
apply
Assessing all peripheral pulses
Assessing and comparing both radial pulses
Asking a second nurse to assess the client pulses
Assessing for edema or other issues that may be restricting peripheral blood flow
Observing for pallor or skin, temperature, differences distal to the weak pulse - ANS-✅All responses are
correct
Which question with the nurse asked the client on obtaining their health history? Select all that apply.
Tell me about your food habits
Do you use alcohol or tobacco?
Have you sustained any personal loss recently?
Have you ever experienced any allergic reactions?
Does any family member have a long-term illness? - ANS-✅Food, habits, alcohol or tobacco, allergic
reactions
The nursing student, under the supervision of the registered nurse, plans to perform a post assessment.
While preparing to assess the client, the RN asked the student to check the apical pulse after assessing
the radio poles. Which rationale supports the RNs request?
The client may have a dysrhythmia
The client may have physiologic shock
The client underwent surgery earlier in the day
The client may have peripheral artery disease - ANS-✅The client may have a dysrhythmia
Rationale:
SET WITH QUESTIONS AND ANSWERS
The nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally declares
with coughing. Which condition would the nurse associate with the sounds?
Parietal pleura, rubbing against visceral pleura
Random sudden reinstallation of groups of alveoli
Turbulence due to muscular spasm and fluid or mucus in the larger airways
High velocity, air flow through a severely narrowed or obstructed airway - ANS-✅Turbulence due to
muscular spasm and fluid or mucus in the larger airways
Rationale:
Loud, low pitched, rumbling course sounds heard over the trachea and bronchi = turbulence caused by
muscular spasm when fluid or mucus is present in the larger airways.
Pleural rub = sound of dry or grading quality, best heard in the lower portion of the anterior lateral long.
Random and sudden reinflation of groups of alveoli = crackling sounds predominantly heard in the left
and right lung bases.
High velocity, air flow through severely narrowed or obstructed airway = wheezing sound heard all over
the lung
When obtaining a health history, from the newly admitted, client who has chronic pain in the right knee,
which pain assessment data, would the nurse include? Select all that apply.
Pain, history, including location, intensity, and quality of pain
Clients purposeful body movement, and arranging the papers on the bedside table
Pain pattern, including precipitating in alleviating factors
Vital signs, such as increase blood pressure and heart rate
The clients family statement about increases in pain with ambulation - ANS-✅Pain, history, including
location, intensity, and quality of pain
Pain pattern, including precipitating, and alleviating factors
Rationale:
The initial pain assessment should include information about the location, quality, intensity, onset,
duration, and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a
secondary assessment related to the initial.
The nurse assesses bilateral plus for peripheral edema well assessing a client with heart failure and
peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?
Shift of fluid into the interstitial spaces
Weakening of the cell wall
Increased intravascular compliance
Increased intracellular fluid volume - ANS-✅Shift of fluid into the interstitial spaces
Which client is at risk for heart disease?
Client one - red, face, area of trauma, sacrum, shoulders
Client two - bluish, nail beds, lips, mouth, skin
,Client three - pallor, face, conjunctivae, nail beds, palms of hands
Client four - yellow, orange, sclera, mucous membranes, skin - ANS-✅Client two
Rationale:
These symptoms may be due to an increased amount of deoxygenated, hemoglobin, which may be due
to heart or lung disease. Client one would indicate fever or trauma. Client three would indicate anemia.
Client number four would indicate jaundice or liver disease.
The nurse assesses the length of a client, auscultates soft, crackling, bubbling breath sounds that are
more obvious on inspiration. Which term with the nurse use to document the sounds?
Vesicular
Bronchial
Crackles
Rhonchi - ANS-✅Crackles
Rationale:
Crackles are abnormal breath sounds described as soft, crackling, bubbling, sounds, produced by air,
moving across fluid in the alveoli .
Rhonchi or abnormal breath, sounds heard over the large airways of the lungs, and consist of a low pitch
and are caused by the movement of secretions in the larger airways; they usually clear with coughing
The secular breath sounds are normal they are quiet, soft, and inspiration sounds that are short and
almost silent on expiration and heard over the long periphery.
Bronchioles breath sounds are normal and consist of a full inspiration and expiratory phase with the
expiratory phase, being louder, and are heard over the trachea and large bronchi of the lungs.
During orientation, a registered nurse reviews Contant about the third heart sound S3 with recently
employed nurses. Which participants statement indicates ineffective learning?
S3 is heard in clients with heart failure
S3 is a normal sound in pregnant women
S3 is abnormal and adults over 31 years of age
S3 is normal in children and young adults - ANS-✅S3 is normal in pregnant women
Rationale:
A third heart sound can be heard when the heart attempts to fill an already distended ventricle. This
sound may be common and normal in the last stages of pregnancy, but not in all stages. The sound may
be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. The sound is
normally heard in children and young adults .
Which client's assessment playing correctly yield's effective results?
Ulnar - ulnar side of forearm at the wrist - cardiac arrest one other sites are not palpable
Carotid - along the medial edge of the sternocleidomastoid muscle in the neck - presence of owner
blood flow
Dorsalis pedis - along the top of the foot - status of circulation to the foot
Posterior tibial - above the medial malleolus - status of circulation to the foot - ANS-✅Dorsalis pedis
Rationale:
Owner site is used to assess the status of circulation to the hand and to perform the Allen test. The
carotid site is used to assess in times of physiological shock or cardiac arrest when other sites are not
, palpable. The posterior tibial site is found below, not above, the medial malleolus, and is used to assess
the status of circulation in the foot.
Which step of the nursing process involves the nurse interviewing a client about current health problem
and obtaining the clients vital signs?
Planning
Diagnosis
Assessment
Implementation - ANS-✅Assessment
Which site with the nurse prefer to assess for determining the turgor of an older adult select all that
apply
Back of the neck
Back of the hand
Palm of the hand
On the sternal area
Back of the forearm - ANS-✅On the sternal area, and back of the forearm
Rationale:
The rest of the sites are not reliable or ideal sites for turgor assessment
Which action would the nurse take for a client whose right radio pulse is weak and thready? select all the
apply
Assessing all peripheral pulses
Assessing and comparing both radial pulses
Asking a second nurse to assess the client pulses
Assessing for edema or other issues that may be restricting peripheral blood flow
Observing for pallor or skin, temperature, differences distal to the weak pulse - ANS-✅All responses are
correct
Which question with the nurse asked the client on obtaining their health history? Select all that apply.
Tell me about your food habits
Do you use alcohol or tobacco?
Have you sustained any personal loss recently?
Have you ever experienced any allergic reactions?
Does any family member have a long-term illness? - ANS-✅Food, habits, alcohol or tobacco, allergic
reactions
The nursing student, under the supervision of the registered nurse, plans to perform a post assessment.
While preparing to assess the client, the RN asked the student to check the apical pulse after assessing
the radio poles. Which rationale supports the RNs request?
The client may have a dysrhythmia
The client may have physiologic shock
The client underwent surgery earlier in the day
The client may have peripheral artery disease - ANS-✅The client may have a dysrhythmia
Rationale:
