N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide 6. When examining the teeth and gums, the nurse should be concerned if: a. The gums are receding off the teeth. b. The adult patient has less than 32 teeth. c. The gums are pink and firm. d. The tooth enamel is off white and shiny. 7. When assessing the chest and thorax, the nurse hears vesicular breath sounds in the upper lung fields. The astute nurse: a. Should be concerned and report this abnormal finding. b. Should be concerned, but watch for any increase in the abnormal sounds. c. Should not be concerned; although not normal, this finding is not cause for concern. d. Should not be concerned; this is a normal finding. 8. The nurse auscultates the heart sounds of a 65-year-old female and notes the presence of an S3 heart sound. The astute nurse: a. Should be concerned and report this abnormal finding. b. Should be concerned, but watch for any increase in the abnormalsounds. c. Should not be concerned; although not normal, this finding is not cause for concern. d. Should not be concerned; this is a normal finding. 9. The nurse is assessing capillary refill in an adult patient. The nurse should be concerned if: a. The nail bed blanches when pressure is applied. b. The color returns to the nail bed within five seconds. c. The nail bed is pink and symmetrical bilaterally after the test. d. The patient expresses some discomfort when the capillary bed is compressed. 10. The nurse is auscultating the abdomen of a patient immediately after the patient's return from abdominal surgery. The nurse notes hypoactive bowel sounds in all quadrants. The astute nurse: a. Should be concerned and report this abnormal finding. b. Should call the surgeon immediately. c. Should not be concerned; although not normal, this finding is expected. d. Should not be concerned; this is a normal finding. The answer key is on page 129.

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