The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:

When part of the lung is obstructed or collapsed

When bulging of the intercostal spaces is present

In an obese patient

When accessory muscles are used to augment respiratory effort

Answer and Explanation

The Correct Answer is A

A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.

B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.

C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.

D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.

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Correct Answer is D

Explanation

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

A. Checks the instrument gauge to ensure the reading starts at zero B. Centers the cuff bladder over the client's brachial artery C. Places the client's arm above the level of the client's heart D. Wraps the blood pressure cuff around the client's arm using firm pressure

Correct Answer is C

Explanation

A. Checks the instrument gauge to ensure the reading starts at zero:

This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.

B. Centers the cuff bladder over the client's brachial artery:

This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.

C. Places the client's arm above the level of the client's heart:

This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.

D. Wraps the blood pressure cuff around the client's arm using firm pressure:

This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.

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The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Correct Answer is D

Explanation

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Correct Answer is C

Explanation

A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

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