Exam 4 NUR 233 Practice Questions and Correct Answers
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Course
NUR 233
Institution
NUR 233
A patient with right ventricular failure asks the nurse about this condition. Which information should the nurse include in the explanation? Select all that apply. 1 The right ventricle doesn't function well, and fluid backs up in the systemic circulation. 2 There may be an enlargement of the liver...
Exam 4 NUR 233 Practice Questions and
Correct Answers
A patient with right ventricular failure asks the nurse about this condition. Which
information should the nurse include in the explanation? Select all that apply.
1
The right ventricle doesn't function well, and fluid backs up in the systemic circulation.
2
There may be an enlargement of the liver and spleen.
3
The right ventricle doesn't function well, and fluid backs up in the lungs.
4
There is pulmonary edema and fluid accumulation in the lungs.
5
There may be peripheral edema of the hands and feet. ✅1, 2, 5
In right ventricular failure, the right ventricle of the heart does not function well, resulting
in a backup of fluids in the systemic circulation. This backup exerts pressure on various
organs and leads to the enlargement of the liver and spleen. There is also a fluid
accumulation in the extremities presenting as edema. In left ventricular failure, the fluid
backs up in the lungs causing pulmonary edema.
Which statement is true regarding chest percussion?
Multiple choice question
Chest percussion involves slow striking of the chest wall.
Chest percussion is performed over a multilayer of clothing.
Chest percussion involves rhythmically clapping on the chest wall.
Chest percussion is commonly performed on patients who have osteoporosis. ✅Chest
percussion involves rhythmically clapping on the chest wall.
Chest percussion involves rhythmically clapping on the chest wall. It involves striking
the chest wall vigorously. It is performed over a single layer of clothing and is
contraindicated in patients who have osteoporosis.
During assessment a patient states, "It's hard for me to breathe and I feel short-winded
all the time." Which is the most appropriate terminology for the nurse to use when
documenting this assessment?
, Multiple choice question
Apnea
Dyspnea
Tachypnea
Respiratory fatigue ✅Dyspnea
Dyspnea is a subjective description reflective of the patient's statement indicating
difficulty in breathing. Apnea refers to absence of breathing. Tachypnea refers to an
increased rate of breathing, usually greater than 20 breaths per minute. Respiratory
fatigue is a subjective description. It usually refers to the patient exhibiting signs and
symptoms associated with a comprehensive respiratory assessment. The respiratory
assessment includes laborious breathing, use of accessory muscles, and slowing of
respirations.
When examining a patient with dyspnea, for which clinical findings should the nurse
observe?
1
Nasal flaring
2
Increased respiratory rate
3
Decreased respiratory rate
4
Exaggerated respiratory effort
5
Decreased depth of respirations ✅1,2,4
Dyspnea is a clinical sign of hypoxia in which the patient experiences difficulty in
breathing. Nasal flaring is observed as the patient tries to breathe more oxygen.
Increased respiratory rate is noted as the respirations become rapid to compensate for
the deficiency of oxygen. Exaggerated respiratory efforts are seen due to the use of
accessory breathing muscles to compensate for the increased demand for oxygen. The
respiratory rate does not decrease, but increases to compensate for the increased
demand for oxygen. The depth of respiration is increased, rather than decreased, and
respiration becomes rapid to compensate for the deficiency of oxygen.
The nurse is caring for a patient who was admitted to the hospital with a diagnosis of
left-sided heart failure. While assessing the patient, which signs and symptoms would
the nurse likely find?
1
Dyspnea
2
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