CPNRE Client Health Assessment 2

Question 1

During a focused respiratory assessment, the practical nurse auscultates high-pitched musical sounds on exhalation. How are these best described?

Accepted Answer

Wheezes

Answer

Crackles

Answer

Stridor

Answer

Rhonchi

Question 2

A client opens eyes to voice, speaks confused words, and localizes pain. What is the Glasgow Coma Scale total?

Accepted Answer

12

Answer

9

Answer

10

Answer

11

Question 3

When assessing a wound for infection, which finding is most concerning?

Accepted Answer

Increased warmth, redness, purulent drainage, and fever

Answer

Slight pink discoloration at wound edges on day 2

Answer

Mild serosanguinous drainage in first 24-48 hours

Answer

Approximated wound edges with mild bruising

Question 4

The apical pulse is 96 bpm but the radial pulse is 78 bpm. How should this be documented?

Accepted Answer

Pulse deficit of 18 beats per minute

Answer

Tachycardia with regular rhythm

Answer

Bradycardia at 78 bpm

Answer

Normal heart rate with peripheral vasoconstriction

Question 5

In what order should abdominal assessment techniques be performed?

Accepted Answer

Inspection, auscultation, percussion, palpation

Answer

Palpation, auscultation, percussion, inspection

Answer

Inspection, percussion, palpation, auscultation

Answer

Auscultation, inspection, percussion, palpation

Question 6

A postoperative extremity is pale, cold, and the client reports numbness and tingling. What does this indicate?

Accepted Answer

Compromised arterial circulation requiring emergency assessment

Answer

Normal postoperative finding

Answer

Venous congestion from dependent positioning

Answer

Normal inflammatory response