Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

Use of accessory muscles

Nail bed greater than 160 degrees

Circumoral cyanosis

Pursed lip breathing

Anteroposterior-to-transverse diameter of 1:1

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Use of accessory muscles

Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.

B. Nail bed greater than 160 degrees

Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.

C. Circumoral cyanosis

Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.

D. Pursed lip breathing

Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.

E. Anteroposterior-to-transverse diameter of 1:1

Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.

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Correct Answer is A

Explanation

A. AV node - SA node - bundle of His - bundle branches:

This sequence is incorrect. The SA node (sinoatrial node) initiates the electrical impulse in the heart, followed by the AV node (atrioventricular node), bundle of His, and then the bundle branches.

B. SA node - AV node - bundle of His - bundle branches:

This sequence is correct. The electrical stimulus of the cardiac cycle starts at the SA node, which is the natural pacemaker of the heart. From the SA node, the impulse travels to the AV node, then to the bundle of His, and finally to the bundle branches, which distribute the impulse to the ventricles, causing them to contract.

C. Bundle of His - AV node - SA node - Erb's Point:

This sequence is incorrect. Erb's Point is a point on the chest where heart sounds S2 and S3 can be heard most distinctly.

D. AV node - SA node - bundle of His - Erb's Point:

This sequence is incorrect. The AV node comes after the SA node in the electrical conduction system of the heart. Erb's Point is not a part of the normal cardiac conduction pathway; it is a location for auscultation on the chest.

A. Xiphoid process. B. Suprasternal notch. C. Sternal angle. D. Costal angle.

Correct Answer is C

Explanation

A. Xiphoid process:

The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum (breastbone). It does not play a role in the bifurcation of the trachea.

B. Suprasternal notch:

The suprasternal notch, also known as the fossa jugularis sternalis or jugular notch, is the visible dip in the superior part of the manubrium of the sternum between the clavicular notches. It is an important anatomical landmark for assessing the position of the trachea during emergency situations but is not the location of tracheal bifurcation.

C. Sternal angle (Angle of Louis):

The sternal angle, or Angle of Louis, is a palpable notch located at the articulation of the manubrium and the body of the sternum. It is where the second rib attaches and serves as a useful reference point for counting ribs and locating internal structures like the tracheal bifurcation.

D. Costal angle:

The costal angle is the acute angle formed by the junction of the costal margins at the xiphoid process. It is not related to the tracheal bifurcation.

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Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the sequence of the cardiac cycle. The nurse recognizes that the electrical stimulus of the cardiac cycle follows which sequence?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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