When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

a sign of congestive heart failure

a normal finding in a healthy adult.

seen in patients with kyphosis.

indicative of a pneumothorax.

an expected finding in a patient with a barrel chest.

Answer and Explanation

The Correct Answer is C

A. CVA tenderness is associated with renal issues, not directly with congestive heart failure.
B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.
C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.
D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.
E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.

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Correct Answer is ["A","B","E"]

Explanation

A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.

A. Call another nurse for help B. Give pain medication as ordered C. Call the admitting healthcare provider D. Tell client to remain calm E. Apply oxygen via nasal cannula as ordered

Correct Answer is E

Explanation

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply

Correct Answer is ["A","B","E"]

Explanation

A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Correct Answer is E

Explanation

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