min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."

Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."

Reports decreased urination in the past day.

Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."

Diagnostic Results

1030:

Chest x-ray.

Areas of increased density and white infiltrates to lower right lobe.

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

decreased urine output

headache

respiratory assessment

Chest X-ray

Religion

Bowel sounds

perception of needles

Question Solution

Correct Answer : A,C,D

A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.

B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.

C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.

D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.

E. Religion: This does not relate to the clinical findings associated with pneumonia.

F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.

G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.

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A. Petechiae B. Blood pressure C. Cyanosis D. Nausea

Correct Answer is D

Explanation

A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.

B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.

C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.

D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.

A. The diaphragm of the stethoscope is used for low-pitched sounds. B. The binaural should fit snugly in the ears. C. Short tubing provides the listener with the most accurate sounds. D. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. E. The stethoscope works by blocking out environmental sounds.

Correct Answer is ["B","C","E"]

Explanation

A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.

B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.

C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.

D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.

E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.

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Correct Answer is D

Explanation

Correct Answer is ["B","C","E"]

Explanation

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A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?

Correct Answer is D

Explanation

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assessing a client for early manifestations of rheumatoid arthritis (RA). Which change is a manifestation of RA?

The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)

While performing an abdominal assessment on a patient, the nurse notes an abdomen shape similar to the rounded abdomen only greater. This contour is anticipated in pregnancy and seen in adults with ascites and obesity. What term should the nurse use to document this finding?

Providing a safe and comfortable environment, applying critical thinking, and identifying cues presented by the patient is

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, [normal range: 7.35-7.45] Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45] HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26] Which condition would the nurse analyze these results to indicate?

How should the nurse interpret the rhythm depicted in the image?

When a patient is unable to see objects at a distance, which term is used to document this finding?

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