The nurse percusses a client with COPD and expects to hear:

Tympany

Hyperresonance

Resonance

Dullness

Answer and Explanation

The Correct Answer is B

A.   Tympany is a high-pitched sound typically heard over a hollow organ such as the stomach.
B.   Hyperresonance is often heard in patients with COPD, as the lungs are hyperinflated, leading to an increased resonance when percussed.
C.   Resonance is normal and would be heard in healthy, air-filled lungs.
D.   Dullness would suggest a solid or fluid-filled area, which is not typical of COPD unless there is a complication like pleural effusion.

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Correct Answer is B

Explanation

A. Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B. Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C. Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D. Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.

A. Assess the forearm and hand for infection B. Assess the lower extremities C. Assess the dorsalis pedis pulses D. None of the above

Correct Answer is B

Explanation

A. Assess the forearm and hand for infection would be relevant if the swollen lymph node were in the upper extremity, but the inguinal node would be more associated with a lower extremity infection.
B. Assess the lower extremities is the correct next step since the inguinal lymph nodes drain the lower body, including the legs and genital area.
C. Assess the dorsalis pedis pulses is not the next step, though it may be important if vascular concerns are suspected.
D. None of the above is incorrect because assessing the lower extremities is the next logical step.

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The nurse percusses a client with COPD and expects to hear:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Correct Answer is B

Explanation

The nurse palpates a swollen inguinal lymph node. Which assessment should the nurse perform next?

Correct Answer is B

Explanation

What component of the conduction system is referred to as the pacemaker of the heart?

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A heart murmur should be assessed for which of the following? Select all that apply.

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During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

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