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154- Unit 6 Review Questions

Terms in this set (10)

1. The nurse is listening to the patient's heart at the 2nd LSB. Which area is being auscultated?
1. Erb's point
2. Mitral area
3. Aortic area
4. Pulmonic area
Pulmonic area
*LSB= left sternal border
2. A patient complains of pain in the calf when walking. Which question should the nurse ask for further data?
1. "Does your calf also swell when this pain occurs?"
2. "Does the pain go away when you stop walking?"
3. "Do you become short of breath when you're walking?"
4. "Do you feel dizzy when the pain occurs?"
"does the pain cease when you stop walking"
*we need to determine whether or not the pain is triggered by the walking, and if stopping helps relieve the pain to further diagnose the cause
3. A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding?
1. An opening snap
2. A diastolic murmur
3. A systolic murmur
4. A pericardial friction rub
Systolic murmur
*systolic murmur is a murmur that begins during or after the first heart sound and ends before or during the second heart sound
4. When a patient complains of chest pain, which question is pertinent to ask to gain additional data?
1. "What were you doing when the pain first occurred?"
2. "What does the pain feel like?"
3. "Do you have shortness of breath?"
4. "Has anyone in your family ever had a similar pain?"
"what does the pain feel like?"
*determining the characteristics of the pain can indicate the root cause
5. How does a nurse determine jugular vein pulsations?
1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered
2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position
3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle
4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough
Elevate the head of the bed until the external jugular vein pulsation is seen above the clavicle
6. Where does a nurse palpate the posterior tibial pulse?
1. Behind the knee in the popliteal fossa
2. The inner aspect of the ankle below and slightly behind the medial malleolus
3. Over the dorsum of the foot between the tendons of the first and second toes
4. The outer side of the ankle below and slightly behind the lateral malleolus
Inner aspect of the ankle below and slightly behind the medial malleolus
*medial malleolus is the bump that protrudes on the inner side of your ankle
7. Which finding does the nurse expect during auscultation of the heart?
1. A low-pitched blowing sound is heard over the apex of the heart.
2. A high-pitched vibration is heard over the base of the heart.
3. The S1 heart sound is louder at the apex of the heart.
4. The S3 heart sound sounds like "Ken-tuck-y."
The S1 heart sound is louder at the apex of the heart
*PMI (point of maximal pulse) is loudest at the apex of the heart
8. What is the most accurate technique for detecting a venous thrombosis at the bedside?
1. Measure the thigh circumference to detect an increase from the baseline.
2. Dorsiflex the calf and notice if the patient complains of pain.
3. Elevate one leg above the level of the heart to determine if the veins empty.
4. Palpate the pulses distal to the areas of the suspected thrombosis.
Measure the thigh circumference to detect an increase from the baseline
*deep vein thrombosis is caused by a blood clot deep in the vein, this causes leg pain or swelling; measuring the thigh would indicate swelling
9. Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings?
1. Ms. J, whose blood pressure has been 140/90
2. Mr. Q, whose blood pressure has been 130/76
3. Ms. Y, whose blood pressure has been 120/80
4. Mr. P, whose blood pressure has been 110/78
110/78
10. While inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease?
1. Pitting edema of one or both feet or legs
2. Increased circumference in the thighs bilaterally
3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses
4. Pain when legs are dependent that is relieved when legs are elevated
Pale, cool legs w/ diminished-to-absent dorsalis pedis pulses
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