Answers
The nurse is asking a pt with COPD for clubbing of the fingernails. The nurse recognizes which
finding for positive for clubbing? correct answers Nail bases with an angle of 180 degrees or
greater and that feel spongy
During exam of female patient the nurse notes adenopathy and notices suspects acute infection.
Acutely infected lymph nodes would be correct answers firm but freely moveable
**Acutely infected lymph nodes are bilateral, enlarged, warm and tender. They are firm but
freely movable. Unilaterally enlarged lymph nodes that are firm. non tender may indicate
cancer**
When assessing the patient's lungs the nurse recalls that the left lung correct answers Consists of
2 lobes (because of the heart)
**right lung has 3 lobes**
Ordered: Dilantin 85mg daily
Available: Dilantin suspension 125mg/5ml
How many mL will you give? correct answers 3.4
When assessing the pupillary light reflex, the nurse should use which of the following
techniques? correct answers Shine light across pupil from side and observe for direct and
consensual pupillary constriction
,The nurse is assessing for inflammation in a dark skinned person. Which techniques is the best?
correct answers Palpating the skin for edema and increased warmth
The nurse knows expected normal assessment findings of the lungs in an adult to be: correct
answers Muffled voice sounds and symmetrical tactile fremitus
A visitor from Poland who speaks no English seems to be somewhat apprehensive about the
nurse examining his head and neck. He would probably be more comfortable with nurse
examining his thyroid gland from correct answers the front with the nurses thumbs placed either
side of his trachea and his head tilted back
A 65 year old man with emphysema and bronchitis has come to the clinic for a follow-up. On
assessment, the nurse might expect to see which finding? correct answers clubbing of nails
**Clubbing of nails occurs with congenital heart diseases and neoplastic and pulmonary
diseases.**
The nurse is examining a patient's ears and notices cerumen in the exterior ear canal. Which of
the following statement is correct? correct answers The purpose of cerumen is to protect and
lubricate the ear
The nurse is performing an external eye examination. Which statement regarding the outer layer
of the eye is true? correct answers The outer layer of the eye is very sensitive to touch
**The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer
surface of the eye is stimulated**
What about the retina, inner layer of the eye is true? correct answers This is where light waves
are changed into nerve impulses
, What about the choroid, the middle layer of the eye is true? correct answers This layer contains
the dark pigmentation to prevent light from reflecting internally
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the
nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective
of: correct answers Dehydration
During the exam the nurse knows that the best way to palpate lymph nodes in the neck is: correct
answers Using gentle pressure, palpate bilaterally to compare both sides
A pediatric client has had the following intake today:
½ cup of soup
1 slice of white bread
1/2 cup of fruit loops
2.5 oz green jello
3.5 oz orange popsicle
2 vanilla wafers
45 ml fruit punch
6 oz of warm milk