A patient on the cardiac ﬂoor has just had a PlCC line placed by the MD. the Xray team has not verified the position of the catheter tip, yet. You check the heart monitor and notice she begins having an irregular heart rhythm called Atrial Fibrillation. You anticipate that the PlCC line is touching which chamber of the heart?

Left Ventricle

Right Ventricle

Right Atria

Left Atria

Answer and Explanation

The Correct Answer is C

A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.

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Correct Answer is B

Explanation

Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with ﬂuid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.

Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.

Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.

A. Three B. One C. Four D. Two

Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Three defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice B reason: This is correct because it shows that the PN is familiar with the nursing diagnosis criteria. One defining characteristic is the least number required for the diagnosis of Impaired Verbal Communication, according to the NANDA-I taxonomy.

Choice C reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Four defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice D reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Two defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

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Naxlex Comprehensive Predictor Exams

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

Correct Answer is B

Explanation

The Practical Nurse (PN) assessing a client for the nursing diagnosis of Impaired Verbal Communication is aware that the least number of defining characteristics for this diagnosis is:

Correct Answer is B

Explanation

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Respiratory Therapy has an order to perform chest physiotherapy on your patient who has COPD. Your patient’s lung sounds are diminished, but free of secretions. What should the proper response be from the nurse to the respiratory therapist:

KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

The nurse is discussing car safety with the mother of a 6-year-old child. The child’s mother questions the need for the use of special car seats for her child. What information can be provided to her?

A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

A client with renal disease requires IV ﬂuids. It is important for the nurse to: