pg. 1 NUR222 Practice Exam Newest 2024 Complete 150 Potential Questions with Detailed Verified Answers (100% Correct Answers) AGRADE ASSURED!!
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age?
- Increase in resting heart rate
- Increase in systolic blood pressure
- Decrease in diastolic blood pressure
- Increase in diastolic blood pressure
ANS: B
With aging, an increase in systolic blood pressure occurs. No significant change in diastolic pressure and no change in the resting heart rate occur with aging. Cardiac output at rest is does not changed with aging.
The nurse knows that auscultation of fine crackles would most likely be noticed in:
- A healthy 5-year-old child.
- A pregnant woman.
- The immediate newborn period.
- Association with a pneumothorax.
ANS: C
Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis. 1 / 4
pg. 2 During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?
- In an obese patient
- When part of the lung is obstructed or collapsed
- When bulging of the intercostal spaces is present
- When accessory muscles are used to augment respiratory effort
ANS: B
Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain.
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?
- Airway obstruction
- Emphysema
- Pulmonary consolidation
- Asthma
ANS: C
Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony
The nurse is reviewing the characteristics of breath sounds. Which statement about
bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
- Musical in quality.
- Usually caused by a pathologic disease.
- Expected near the major airways.
- Similar to bronchial sounds except shorter in duration.
ANS: C
Bronchovesicular breath sounds are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct. 2 / 4
pg. 3 The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?
- Wheezes
- Bronchial sounds
- Bronchophony
- Whispered pectoriloquy
ANS: A
Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?
- Unequal chest expansion
- Increased tactile fremitus
- Atrophied neck and trapezius muscles
d. Anteroposterior-to-transverse diameter ratio of 1:1
ANS: D
An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath."
The nurse's best response to this would be:
- "When was your last electrocardiogram?"
- "It's probably because it's been so hot at night."
- "Do you have any history of problems with your heart?"
- "Have you had a recent sinus infection or upper respiratory infection?" 3 / 4
pg. 4
ANS: C
Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?
- Family history, hypertension, stress, and age
- Personality type, high cholesterol, diabetes, and smoking
- Smoking, hypertension, obesity, diabetes, and high cholesterol
- Alcohol consumption, obesity, diabetes, stress, and high cholesterol
ANS: C
To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post menopausal women, cigarette smoking, and low activity level
The mother of a 3-month-old infant states that her baby has not been gaining weight.With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have?
- Infant's sleeping position
- Sibling history of eating disorders
- Amount of background noise when eating
- Presence of dyspnea or diaphoresis when sucking
ANS: D
To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short time hungry again.
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