HESI REVIEW - RN FUNDAMENTALS

Which component is important in a neurovascular assessment performed by the nurse? - orientation - capillary refill - pupillary response - respiratory rate - pulse and skin temperature - movement and sensation

- capillary refill - pulse and skin temperature - movement and sensation

The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which finding is considered within normal range for this client? Select all that apply. One, some, or all responses may be correct. - oral temperature of 98.2 F - apical pulse of 88 beats/min and regular - respiratory rate of 30 breaths/min - blood pressure of f116/78 mm Hg while in a sitting position - oxygen saturation of 92%

- oral temperature of 98.2 F - apical pulse of 88 beats/min and regular - blood pressure of 116/78 mm Hg while in a sitting position

When performing a focused respiratory assessment, which action would the nurse take first? - examine for any abnormal respiratory patterns - inspect for changes in skin color or temperature - check for any evidence of respiratory distress - determine the shape and symmetry of the chest

check for any evidence of respiratory distress

When assessing a client's blood pressure, the nurse notes that the diastolic blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. Which statement reflects the nurse's understanding of this occurrence? - it is normal occurrence - it may indicate atherosclerosis - it can be attributed to aortic disease - it indicates lymphedema

it is normal occurrence

A client has closed fractures of the right femur and tibia with multiple soft- tissue contusions. Which action would the nurse plan to take? - perform a neuromuscular assessment of the extremity - reassure the client that these injuries are not that serious - gather equipment needed for the application of skeletal traction - prepare the client for a surgical reduction of the injured extremity

perform a neuromuscular assessment of the extremity

Which action would the nurse take to determine a client's pulse pressure? - multiply the heart rate by the stroke volume - subtract the diastolic from the systolic reading - average the systolic and diastolic pressure readings - calculate the difference between apical and radial pulse rates

subtract the diastolic from the systolic reading