NCLEX/ATI/Text Questions - NSG 200 - Respiratory/Cardiovascular Assesment
1. The registered nurse (RN) is educating a new RN on conducting a prob- lem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?
NCLEX/ATI/Text Questions - NSG 200 -
Respiratory/Cardiovascular Asses ment
1. The registered nurse (RN) is educating a new RN on conducting a prob- lem-based or focused
assessment on a client. Which statement by the new RN indicates that the teaching has been
effective?
1. "This is mostly used in a walk-in clinic or emergency department."
2. "This is focused on disease detection and conducted in a health care provider's office."
3. "This is conducted on admission in a primary care or long-term care setting."
4. "This is conducted as a follow-up examination by a health care provider.": 1. "This is mostly used
in a walk-in clinic or emergency department."
Rationale:
A problem-based assessment involves a history and physical examination that is limited to a
specific problem or client complaint and is most often used in a walk-in clinic or emergency
department. A screening assessment is a limited examination focused on disease detection. A
complete assessment includes a complete health history and physical examination and forms a
baseline database. It is performed on admission to a primary care or long-term care setting. An
episodic or follow-up assessment is done when a client is being followed up for a previously
identified or treated problem.
2. The nurse is performing a respiratory assessment and is auscultating the client's breath sounds.
On auscultation, the nurse hears a grating and creak- ing type of sound. The nurse interprets this to
mean that client has which type of sounds?
Rationale:
A pleural friction rub is characterized by sounds that are described as creaking, groaning, or
, NCLEX/ATI/Text Questions - NSG 200 -
Respiratory/Cardiovascular Asses ment
grating. The sounds are localized over an area of inflammation on the pleura and may be heard
in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical
noises heard on inspiration, expiration, or both and are the result of narrowed airway passages.
Rhonchi are usually heard on expiration when there is an excessive production of mucus that
accumulates in the
, NCLEX/ATI/Text Questions - NSG 200 -
Respiratory/Cardiovascular Asses ment
air passages. Crackles have the sound that is heard when a few strands of hair are rubbed
together and indicate fluid in the alveoli.
3. A nursing student is performing a respiratory assessment on an adult client and is assessing for
tactile fremitus. Which action by the nursing student indicates a need for further teaching?
1. Palpating over the lung apices in the supraclavicular area
2. Asking the client to repeat the word ninety-nine during palpation
3. Palpating over the breast tissue to assess and compare vibrations from one side to the other
4. Comparing vibrations from one side to the other as the client repeats
the word ninety-nine: 3. Palpating over the breast tissue to assess and compare vibrations from
one side to the other
Rationale:
When assessing for tactile fremitus, the nurse would begin palpating over the lung apices in the
supraclavicular area. The nurse would compare vibrations from one side to the other as the clien
repeats the word ninety-nine.
4. The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the
diaphragm of the stethoscope over which cardiac site?
1. Mitral area
2. Right atrium
3. Right ventricle
4. Pulmonic valve: 1. Mitral area
Rationale:
The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apica
pulse. S1 (lub) and S2 (dub) would be distinguished. The pulse would be counted for a full
minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear
auscultation of the apical pulse.
5. A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for
, NCLEX/ATI/Text Questions - NSG 200 -
Respiratory/Cardiovascular Asses ment
the client monitors the status of breath sounds in that area by placing the stethoscope at which
location?
1. Near the lateral 12th rib
2. Just under the left clavicle
3. In the fifth intercostal space
4. Posteriorly under the left scapula: 2. Just under the left clavicle
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