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NURS6700 Exam II Questions And Accurate Answers
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NURS6700 Exam II Questions And Accurate Answers2024-2025
AD-PIE Nursing Process
Assessment
Diagnosis
Outcomes/Planning
Intervention
Evaluation
Assessment-Answer Gathering subjective and objective data
Diagnosis-Answer Must be NANDA approved [only nursing diagnoses, not medical]
Outcomes/Planning-Answer Goals must be specific to patient and have a time attached
to them
Intervention-Answer What will you/the PT do to achieve the goals set?
Evaluation-Answer Answers the questions, did you meet your goal?
The 3 Part Nursing Diagnosis - Answer 1. Review NANDA approved list and identify
proper diagnosis
2. Identify cause of problem [diagnosis is NOT the cause]
3. Provide evidence to support nursing diagnosis
,Nursing Diagnosis Facts - Answer - Focused on the scope of nursing practice
- Errors can occur from inadequate assessment
- Must contain all three parts to be complete
4 Quadrants of the abdomen - Answer RUQ, LUQ, LLQ, RLQ
When listening to the abdomen you should. -Answer hear tympany, except when over a
muscle, organ, or mass in which case you will hear dull sounds.
Location of organs in abdomen -Answer
Liver span -Answer Mapping edge of liver using percussion. Do this to determine length
and width Normal is 6-12cm
Costo-vertebral Angle - Answer Area of back where kidneys are located. Assess this
location for tenderness or inflammation in relation to kidneys.
Flank Area - Answer One side of the body, (either L or R), between the abdomen and
back. [if left flank pain is present, this is a sign of kidney failure]
Ascites - Answer Excess fluid build up in parietal space of abdomen
Abdominal Aortic Aneurysm - Answer Dilatation of abdominal aorta [when > 3cm or >
50% the size of normal]
Respiratory System - Answer
Abdominal Assessment - Answer Inspection
Auscultation
Percussion
, Palpation
Auscultation (back) - Answer Always compare for symmetry!
Auscultation (front) - Answer Always compare for symmetry!
Normal vs. Adventitious Lung Sounds - Answer In a normal air-filled lung, one can hear
vesicular sounds over most of the lung fields, bronchovesicular sounds between the 1st
and 2nd interspaces on the anterior chest, bronchial sounds over the body of the
sternum, and tracheal sounds over the trachea.
Wheezing is sometimes called - Answer Rhonchi
Crackles are sometimes called - Answer Rales
Normal vs. Adventitious Percussion - Ans. Resonance in healthy lung tissue and
hyper-resonance usually in COPD patients
Pleural Friction Rub - Ans. Sound is dry rubbing or grating. Usually caused by
inflammation in the pleural spaces.
Tactile Fremitus - Ans. Using palpation, ask patient to say "99" and feel for vibration in
chest wall. Compare L and R sides.
Change in Fremitus is only caused by gross changes, small affected areas will not affect
it
Hypoxia - Answer Lack of oxygen at the tissue level
Hypoxemia - Answer Oxygen in blood is below normal
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