VNSG 1323: Chapter 13 Prep U Questions || All Answers Are Correct 100%.
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VNSG 1323:
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VNSG 1323:
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? correct answers Moisture in air passages
Explanation: Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in ...
VNSG 1323: Chapter 13 Prep U Questions || All Answers Are
Correct 100%.
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?
correct answers Moisture in air passages
Explanation: Crackles are fine-to-coarse crackling sounds made as air moves through wet
secretions. They are described as "fine" when air passes through moisture in small air passages,
and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. A
wheeze is produced by narrowed air passages. The lungs normally contain air.
A nurse uses percussion to assess a client's liver. What is the normal tone that should be heard in
this situation? correct answers Dull
Explanation: A medium dull sound is heard over the liver; a flat sound is heard over bone or
muscle. Resonance is a loud, hollow, low-pitched sound heard over a normal lung, and tympany
is a high-pitched, loud, drumlike sound produced over the stomach.
A client is brought to the emergency department after being involved in a motor vehicle accident
and sustaining a head injury. The nurse is performing a Full Outline of Un-responsiveness Coma
Scale (FOUR) to determine the presence of increased intracranial pressure and client outcomes.
What components of the assessment will the nurse document? Select all that apply. correct
answers Eye response
Motor response
Respiration
Brainstem reflexes
Shape
Explanation: The FOUR coma scale combines the most important neurologic signs into an easy-
to-use scale with four components. The maximum score in each of these components is 4. The
components are not totaled or summed and can be used to detect decreasing consciousness,
increasing intracranial pressure, and brain herniation, as well as predict patient outcomes. The
four components are: eye response, brainstem reflexes, respirations, and motor responses.
During the assessment of a client, the nurse places a paper towel on the weighing scale before the
client stands barefoot on it. What is the purpose of this intervention by the nurse? correct
answers To reduce contact with microorganisms on the equipment
Explanation: A paper towel is placed on the scale before the client stands barefoot on it to reduce
contact with microorganisms on the equipment that other people use. The scale needs to be
calibrated to zero to ensure that the client's weight is measured accurately and there is no chance
of zero error. The paper towel does not help to overcome the chances of zero error in the
equipment. A heavier weight is positioned in a calibrated groove of the scale arm to provide a
rough approximation of the gross body weight.
, A nurse is planning to obtain a weight on an obese client who has a history of falls. What is the
best way to obtain the client's weight? correct answers Use an electronic bed scale.
Explanation: mNurses use an electronic bed or chair scale to weigh medically unstable clients,
clients who are extremely obese, and clients who cannot stand. Assisting the client to stand at the
bedside, transfer to a chair or delegating this task to assistive personal places this client at risk of
falls.
A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe
about the client's posture? correct answers The shoulder and upper back curves forward.
Explanation:In kyphosis, the shoulder and upper back tend to curve forward. In lordosis, the
lumbar region curves inward and the sacral region curves outward. Scoliosis is a curvature of a
portion of the spine to the side, laterally.
The nurse is performing the positions test on a client following a head injury. Which assessment
would the nurse interpret as a normal finding? correct answers Coordinated movement of both
eyes
Explanation: Eye movements are controlled by several pairs of eye muscles. During the positions
test, the nurse observes extraocular movements by asking the client to focus on and track the
nurse's finger or some other object as it moves in each of six positions. During the assessment,
both eyes should move in a coordinated manner. Limited movement in one eye may indicate
cranial nerve damage; irregular or uncoordinated movement, such as nystagmus, may suggest
other neurologic pathology.
While assessing the characteristics of the skin of the client, the nurse observes a mouth slit at the
aperture of the mouth. The nurse documents this finding as a fissure. What is a fissure? correct
answers A crack in the skin, especially in or near a mucous membrane
Explanation: A fissure is a crack in the skin, in or near a mucous membrane. An abrasion is an
area that has been rubbed away by friction. A scar is a mark left by the healing of a wound or
lesion. An ulcer is an open, crater-like area on the skin.
The nurse on a geriatric care unit is completing assessments of four clients. Which client is most
likely to exhibit edema? correct answers An 81-year-old woman who has been admitted with
chronic heart failure
Explanation:Edema is particularly common in clients with cardiovascular, liver, and kidney
dysfunction. Consequently, the nurse should carefully assess for edema in a client with CHF.
Prostate disease, head injury, and foot ulcers are not closely associated with edema.
The nurse conducting a physical assessment can encourage the client to be honest and open in
identifying the health problem by: correct answers Explaining that all information will be kept
confidential.
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