Fundamentals of Nursing NCLEX Style
82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. HR 2. Skin turgor 3. Smoking history 4. Allergies to antibiotics 5. Recent BM's 6. BP in right arm 7. Client's normal temperature 8. BP in distal extremity
1, 2, 4, 7
Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37.3 (99.4) 4) HR= 72 BPM 5) RR= 28 BrPM
1, 5, 2, 4, 3
How frequently is vital sign assessment done for stable patients?
4 to 8 hours
Irregular and apical pulses should be counted for
60 seconds
There are many methods of transmission of infection. Which is the best example of a vehicle of transmission?
A health care worker's hands, hospital equipment, or instruments
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.
A- Check the client's temperature history. (looking for a fluctuation in temperature)
Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy? A. Checking frequently for soiling B. Washing the perineal area with strong soap and water C. Placing the call light within easy reach D. Keeping a pad under the patient
A. Checking frequently for soiling
You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. B. Insist that you are supposed to complete the care. C. Honor the patient's request to complete her own perineal care to avoid any embarrassment. D. Ask the patient if a family member can complete the care instead.
A. Explain to the patient that, because of her symptoms, you need to observe the perineal area.
The nurse is completing a postoperative assessment on a patient in the postanesthesia recovery unit. Which VS requires further assessment by the nurse for possible hypovolemic (low blood volume) shock? a. An increase in heart rate b. An increased temperature reading c. A decrease in blood pressure d. A decrease in respiratory rate
ANS: A The initial response of shock occurs when baroreceptors detect a drop in mean arterial pressure, which initiates the compensatory mechanisms of increased heart rate and increased respiratory rate. Temperature will drop as shock progresses. A decrease in blood pressure is a later sign of shock than the increase in heart rate and increase in respiratory rate.
The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is best? a. Assess the patient for fluid volume overload. b. Assess the patient for fluid volume deficit. c. Assess the patient's apical heart rate. d. Assess the patient's pulse deficit.
ANS: A A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume overload, or overhydration. The nurse should assess for this situation. The other actions are not necessary.
A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best? a. Instruct the patient not to get up without help. b. Document the findings and continue to monitor. c. Reassure the patient that these findings are normal. d. Reassess the blood pressures in 1 hour.
ANS: A This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.
The nurse understands that which statements regarding blood pressure and blood pressure measurement are true? (Select all that apply). a. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure. b. The patient should be in a comfortable lying or sitting position when taking the blood pressure. c. Maximum blood pressure is created in the arteries when the right ventricle pushes blood into the aorta. d. The difference between systolic pressure and diastolic pressure is known as pulse deficit. e. The point on the gauge where the first faint but clear sound appears is known as diastolic pressure.
ANS: A, B It is correct that systolic is the highest pressure within the artery and diastolic pressure is the lowest. Preferred positions for assessing blood pressure are either lying or sitting with the cuff at heart level. Maximum pressure is created when the left ventricle contracts and falls as the heart relaxes. Pulse deficit is the difference between the apical and radial pulse rates. Systolic pressure is recorded as the first faint but clear sound heard.
The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.) a. Brain b. Lungs c. Heart d. Liver e. Skeletal muscle
ANS: A, B, C Problems in the brain, heart, and lungs can directly lead to changes in respiratory rate and effort. Problems in the liver and skeletal muscle do not affect respirations directly.
The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.) a. Monitor body systems functioning. b. Identify early signs of problems. c. Evaluate effectiveness of interventions. d. Determine if a cure has been obtained. e. Provide a baseline to compare against.
ANS: A, B, C, E Vital signs give information on the functioning of body systems, can lead the nurse to identify early signs of problems, can be used to evaluate the effectiveness of interventions, and provide a baseline to compare against subsequent readings. They are not used to solely determine if a disease has been cured.
A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.) a. Agitation b. Restlessness c. Sighing d. Vital signs e. Shivering
ANS: A, B, D The American Society for Pain Management in Nursing's position paper states that for the unconscious, intubated, dementia, or pre-verbal pediatric patient objective assessments of agitation, restlessness, irritation, and changes in vital signs can be used to help assess pain.
A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) A. Allow the patient to perform as much of the care as possible. B. Start by washing the face. C. Try an alternative to traditional bathing such as the "bag bath." D. Use restraints to prevent the patient from injuring self or the nurse.
ANS: A, C A. Allow the patient to perform as much of the care as possible C. Try an alternative to traditional bathing such as the "bag bath."
Which parameters does the nurse include when assessing pain? (Select all that apply.) a. Facial expression b. Muscle spasms c. Shallow respirations d. Immobility e. Temperature
ANS: A, C, D Some objective observations can be helpful in indicating pain, although they are not as reliable as the patient's report. These include facial expression, shallow or rapid respirations, increases in respiratory and pulse rate, and increased blood pressure. The patient may also be reluctant to move if he/she is in pain. Temperature is not affected.
The nurse understands that which factors can increase blood pressure? (Select all that apply.) a. Head injury b. Decreased fluid volume c. Increasing age d. Recent food intake e. Pain
ANS: A, C, D, E Head injury, increasing age, recent food intake, pain, and increased (not decreased) fluid volume all can increase blood pressure.
A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.) A. Finding a female nurse to help the patient B. Convincing the patient that he will work quickly and provide as much privacy as possible C. Skipping hygiene care for the day except for the parts that the patient can complete independently D. Asking the patient if she prefers a family member assist with the care
ANS: A, D
The nurse is caring for a patient with a temperature of 103º F, respirations of 30 per minute, pulse rate of 50 beats per minute, and blood pressure of 100/60. The patient is cold and clammy. What does the nurse conclude about these findings? a. The temperature is causing a lowered pulse rate; it will improve if the temperature decreases. b. The low pulse rate is causing a decreased cardiac output, which has caused a low blood pressure. c. The pulse rate and blood pressure are compensatory mechanisms to decrease the increased metabolic rate from the temperature. d. The cool, clammy skin will help to increase the blood pressure and pulse as the body tries to warm the skin.
ANS: B This patient has a low pulse rate with a corresponding low blood pressure—the heart is not maintaining an output high enough to maintain normal blood pressure. A raised temperature will increase the heart rate as the metabolic processes are increased. If the body tries to warm the skin, the temperature would only go higher.
The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? a. Move the oximeter probe to another finger. b. Assess the fingers for good circulation. c. Document that the reading cannot be obtained. d. Remove any fingernail polish present on the fingernail.
ANS: B A patient who is hypothermic may not have good circulation to the extremities. The nurse should assess the patient's circulation, and if it is poor to the extremities, choose another spot at which to measure the oxygen saturation. Moving the probe to another finger or removing nail polish will not help if the problem is poor circulation. The nurse should document appropriately, but needs to do more than just charting that the reading could not be obtained.
A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement? a. Blood pressure 152/98 mm Hg b. Temperature 98.4° F (36.8° C) c. Pulse 82 beats/min d. Respirations 16 breaths/min
ANS: B A temperature of 98.4° F is normal. "Afebrile" means having a normal temperature. The other readings are not related to this term.
A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best? a. Explain to the patient that so much pain is not reasonable. b. Ask the patient to rate and describe the pain. c. Give the patient pain medications as prescribed. d. Call the provider and request an extra dose of pain medication.
ANS: B Pain is a subjective experience and patients' pain experiences will not all be the same. The nurse needs to assess the patient's pain further. After assessing the patient's pain, if it is time for a dose of pain medication, the nurse should administer it. If the nurse's clinical judgment indicates an additional dose of medication is warranted, the provider can be contacted. The nurse should not dismiss the patient's pain by telling him/her that it is unreasonable.
A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best? a. "The patient's metabolic rate is increased from being ill." b. "The lungs are trying to rid the body of extra carbon dioxide." c. "The patient is trying to reduce his temperature through panting." d. "Patients who are acutely ill often have abnormal vital signs."
ANS: B The body tries to compensate for excess carbon dioxide (seen in acidosis) by increasing the rate and depth of respirations to "blow off" the carbon dioxide.
A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? (Select all that apply.) A. Decreasing frequency of oral hygiene B. Applying water-soluble moisturizing gel on the oral mucosa C. Encouraging intake of soft foods D. Using commercial mouthwash
ANS: B, C
Which actions by the nurse could result in a blood pressure measurement error? (Select all that apply.) a. Placing the diaphragm of the stethoscope over the brachial artery b. Using the same cuff for all patients c. Wrapping the bottom edge of the cuff over the antecubital space d. Releasing the valve quickly to prevent patient discomfort e. Taking a measurement after the patient rests quietly for 5 minutes
ANS: B, C, D Patients of different sizes and ages require different size cuffs. The bottom edge of the cuff should not extend over the antecubital space as this prevent proper placement of the stethoscope. Release of the valve too quickly risks missing the initial and final beats.
Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.) A. Remove dentures overnight once a week while they soak in a cleansing bath. B. Do not wear damaged or poorly fitting dentures. C. Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. D. See dentist regularly. E. Rinse dentures after meals. F. Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.
ANS: B, C, D, E
The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.) a. "Let me know if Mr. Smith's blood pressure is low." b. "Take Mrs. Jones' blood pressure every 15 minutes." c. "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg." d. "Do you want me to demonstrate using the electronic blood pressure cuff?" e. "I'll take Mr. Derby's blood pressure since he is not stable."
ANS: B, C, D, E The nurse can delegate measuring vital signs to UAPs if the patient is stable. The nurse must ensure the UAP knows the proper technique for taking vital signs and knows which readings must be reported. Telling the UAP to report a blood pressure that is "too low" is too vague.
The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.) A. Avoid cleaning the feet until an order from the health care provider is received. B. Wash the feet with lukewarm water and then dry well. C. Apply moisturizing lotion to the feet, especially between the toes. D. File the toenails straight across.
ANS: B, D
A nurse is teaching a patient and the patient's family about self-care measures for hypertension. Which topics does the nurse include? (Select all that apply.) a. Increase exercise on most days b. Maintain a normal body weight c. Abstain from any alcohol d. Reduce dietary sodium to 2.4 g/day e. Follow the DASH diet
ANS: B, D, E Self-care measures for hypertension include 30 minutes of aerobic exercise on most days of the week, maintaining a normal body weight, limiting alcohol to two drinks/day for men and one drink/day for women, reducing sodium intake to 2.4 g/day, and following the DASH diet.
The nurse notes that the patient has an irregular pulse. What is the first action the nurse should take? a. Assess the pulse at the carotid artery. b. Assess the pulse with a Doppler ultrasound. c. Assess the pulse for a full minute. d. Assess the pulse at two different sites.
ANS: C Assessing the pulse for a full minute is needed for an accurate count—counting the pulse for a fraction of a minute and then multiplying the value to equal a minute count will give an inaccurate count if the pulse is irregular. The apical pulse, not the carotid, is the site where the pulse should be obtained when there is a question about the count. A stethoscope is sufficient to assess the pulse. The apical pulse would be the first site assessed if there is a question, although the apical and radial pulses are compared to assess for a pulse deficit.
Which assessment findings would require the nurse to further assess the patient? a. A young adult male with a pulse rate of 136 after running 2 miles b. A 40-year-old female with a blood pressure of 110/70 when first awakened c. A 72-year-old female with a respiratory rate of 10 breaths per minute d. A 50-year-old male with a pulse rate of 88 beats per minute
ANS: C Normal respiratory rate is 12 to 20 breaths per minute: rates below this should be further investigated. An increase in pulse rate is expected after aerobic activity. The blood pressure may be lower than other times when first awakened, and the pressure of 110/70 is within normal limits. A pulse rate of 88 is within the normal rate of 60-100 beats per minute for an adult.
The nurse receives a handoff report on four patients. Which patient should the nurse assess first? a. Pain rating 4/10 after pain medication b. Blood pressure 102/62 mm Hg c. Pulse 42 beats/min d. Respiratory rate 18 breaths/min
ANS: C A pulse of 42 beats/min is considered bradycardia and the patient should be assessed first because perfusion could be compromised. The pain rating is not extreme and should be considered in light of the patient's pain goals. The blood pressure and respiratory rate are normal.
A nurse notes a patient has abnormal vital signs. What action by the nurse is best? a. Document the findings. b. Notify the provider. c. Compare with prior readings. d. Retake the vital signs.
ANS: C Individual vital signs are not as important as the trends. For instance, a patient may have a blood pressure higher than "normal" that is normal for the patient. Trends give more useful information than a single reading. Documentation is important, but the nurse needs to do more. If the readings are significantly abnormal, the provider should be notified. The nurse may retake the vital signs if he/she is not confident of the first set of measurements.
A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate? a. Encourage deep breathing and coughing. b. Medicate the patient for pain as needed. c. Keep the head of the bed elevated. d. Monitor the length of time the patient doesn't breathe.
ANS: C Orthopnea is difficulty breathing in positions other than sitting up. To assist the patient who has orthopnea, the nurse keeps the head of the bed elevated to ease breathing.
The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member? a. Counts pulse for 30 seconds and multiplies by two. b. Performs hand hygiene prior to patient contact. c. Compares pulses in both carotid arteries at the same time. d. Assesses pulse on one side then assesses the other side.
ANS: C The carotid arteries are the main supply route of blood to the brain. Compressing both sides of the carotid arteries at the same time can lead to ischemia. The other actions are appropriate.
A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate? a. Take the vital signs again in another hour. b. Document the findings in the patient's chart. c. Have another nurse recheck the vital signs. d. Plan to take the vital signs more often.
ANS: D The nurse uses clinical judgment to determine how often the patient's vital signs should be checked when there is a change in patient condition. The nurse should plan to assess vital signs more often in this patient. Since this is a significant change, the nurse should not wait another hour even though this is what the provider prescribed. It is not necessary for another nurse to double-check the vital signs. Documentation needs to occur, but the priority is to plan to take the vitals more often.
A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure? a. 28 b. 42 c. 58 d. 66
ANS: D The pulse pressure is the difference between the systolic and diastolic blood pressure readings. In this case, 142 - 76 = 66.
The nurse is admitting a stable patient for a minor outpatient procedure. What site would the nurse most commonly use to assess pulse rate? a. Radial site b. Apical site c. Brachial site d. Carotid site
Answer: a The radial site is the most easily accessible and most commonly used site for routine monitoring of pulse rate for a stable patient. The apical site is a very accurate site but requires a stethoscope and access to the chest of the patient. It is used when the pulse is irregular or when certain medication effects are being monitored. The brachial artery can be used for infants and young children in emergency situations and is used to palpate and auscultate blood pressure. A carotid pulse is used when a peripheral pulse cannot be felt.
Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? a. Ambulating for the first time after surgery b. Complaining of pressure in the chest c. Completing ambulating 100 feet after a stroke d. Complaining of hunger while NPO (nothing by mouth)
Answer: b Chest pressure is a classic sign of a heart attack, and vital signs should immediately be checked. Vital signs may be monitored before, during, or after activity, but this is not the most critical need. Unless the vital signs have changed drastically, not having baseline values before ambulation makes it hard to interpret vital signs after activity. Hunger is not a critical indicator for the need for obtaining vital signs.
The nurse understands that which statement is correct regarding respiratory rates? a. Infants have a lower respiratory rate than adults. b. Healthy adults breathe between 12 and 20 times a minute. c. A compensatory response to a fever is to breathe at a slower rate. d. An increase in intracranial pressure results in an increased rate.
Answer: b The normal respiratory rate for a healthy adult is 12 to 20 BPM. Infants have a higher respiratory rate than adults. A fever increases the metabolic rate and results in a higher rate. Intracranial pressure decreases the respiratory rate.
The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this treatment? a. Radiation b. Convection c. Conduction d. Evaporation
Answer: c Conduction is the transfer of heat from a warm object (the patient) to a cooler object (the cooling blanket) during direct contact. Radiation is heat loss from one surface to another without direct contact. Convection is the loss of heat from cool air flowing over a warm body. Evaporation is the conversion of a liquid to a vapor, such as when perspiration evaporates.
It is 6 A.M. and the unlicensed assistive personnel reports to the nurse that the patient has a temperature of 96.7º F (35.9 º C) tympanic. Which factor explains this reading? a. The patient's room is cold. b. The patient was drinking cold water. c. The patient is exhibiting a normal circadian rhythm. d. The patient just completed a warm shower.
Answer: c Normal circadian rhythms cause a lower temperature in the early morning and higher temperature in the late afternoon. A cool room would initially cause compensatory mechanisms such as shivering and a feeling of being cold. Cold water could affect temperature if an oral thermometer was used. A warm shower would not cause a decrease in temperature unless there was a delay in drying the skin and dressing.
The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data would support this evaluation? a. Pulse 88, blood pressure 140/88 b. Pulse 96, blood pressure 120/76 c. Pulse 100, blood pressure 118/80 d. Pulse 114, blood pressure 98/60
Answer: d A pulse over 100 is tachycardia; a blood pressure below 100 systolic is hypotension. All of the other measurements of pulse are within normal limits for an adult, and the blood pressures are within normal limits, except 140/88, for which the systolic pressure is hypertensive but is paired with a pulse in the normal range.
The nurse is measuring blood pressures as part of a community health fair. Which blood pressure reading would cause the nurse to refer the patient for follow-up regarding potential hypertension? a. 118/78 b. 126/84 c. 136/90 d. 144/94
Answer: d A reading of 144/94 has both systolic and diastolic pressures that are considered high and should be referred for additional readings. The other readings are within normal limits, although all patients should be considered for health promotion teaching regarding cardiac health, especially the patient with a blood pressure of 136/90, which is in the prehypertensive category.
When evaluating a patient, what other signs and symptoms may a nurse observe if a hypertension patient is present besides high blood pressure values? A) Unexplained pain and hyperactivity B) Headache, Flushing of the face, and Nosebleed C) Dizziness, Mental Confusion, and Mottled Extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch
B- Headache, Flushing of the face, and Nosebleed
The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.
B- The client has an arrhythmia. (Best way to detect arrhythmia. Utilizing PMI)
The nurse is taking vital signs on a 6 yr old child who has just finished a grape popsicle. Which of the following is an appropriate action? a. wait 30 minutes to take the oral temperature b. proceed to take a tympanic temperature reading c. take a rectal temperature measurement d. have the child rinse out the mouth and take the oral temperature
B- proceed to take a tympanic temperature reading
A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: A. Used clean gloves. B. Did not retract the foreskin before cleansing. C. Used the clean portion of washcloth for each cleansing wipe. D. Used a circular motion to cleanse from urinary meatus outward.
B. Did not retract the foreskin before cleansing.
Too frequent bathing and the use of hot water frequently lead to what? A. Rash B. Dry, flaky skin and loss of protective oils C. Exceptional hygiene D. Reduction of illness and disease
B. Dry, flaky skin and loss of protective oils
The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response? A. Finish the bath quickly B. Help the patient return to bed C. Leave the patient alone to rest in the chair at the sink for a few minutes D. Instruct the patient to take deep breaths and try to relax
B. Help the patient return to bed
What is the priority concern when providing oral hygiene for a patient who is unconscious? A. Thoroughly brushing all tooth and oral surfaces B. Preventing aspiration C. Controlling mouth odor D. Applying local antiseptic such as chlorhexidine
B. Preventing aspiration
You ask the nursing assistive personnel (NAP) to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient's gown and linen. Which of the following requires your immediate attention? A. Room temperature is overly warm. B. Room door is open to the hallway. C. Television volume is too loud. D. Strong odor of urine is detected.
B. Room door is open to the hallway.
The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference
C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." (means the client may be up as desired.)What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.
C- Obtain orthostatic blood pressure measurements.
Which of the following values for vital signs would a nurse address first? A) Heart Rate = 72 bpm B) Respiratory Rate = 28 bpm C) Oxygen Saturation by pulse oximetry = 89% D) Blood Pressure = 160/86 E) Temperature = 37.2° C (99° F), tympanic
C- Oxygen Saturation by pulse oximetry = 89% (Remember ABCs)
While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 B. A patient who prefers a bath in the evening when his wife visits and can help him C. A patient who is experiencing frequent incontinent diarrhea stools D. A patient who has just returned from diagnostic testing and complains of being very fatigued
C. A patient who is experiencing frequent incontinent diarrhea stools
During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to: A. Trendelenburg's. B. Reverse Trendelenburg's. C. Fowler's. D. Semi-Fowler's.
C. Fowler's
Pediculosis Capitis is better known as what highly infectious condition? A. Scabies B. Herpes Simplex C. Head Lice D. Thinning of the hair
C. Head Lice
The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should: A. Bathe twice a week. B. Rinse well after using soap. C. Use hot water for bathing. D. Drink plenty of fluids.
C. Use hot water for bathing.
Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assisted personnel to measure the client's vital signs? A) A client who recently started taking an anti-arrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension
D) A client who is being admitted for elective surgery who has a history of stable hypertension
The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.
D) Recheck the blood pressure, make sure the client is safe, and report the findings.
The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.
D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.
The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.
The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering
D) Vasoconstriction, reduction of blood flow to extremities, and shivering
The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respiration during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respiration. C) Tell the client it is very important to end the conversation so the nurse can count respiration. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
D- Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.
An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic
D- Temperature = 39° C (102° F), tympanic
A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: A. Decrease the chance of infection. B. Help remove dry, flaky skin. C. Prevent skin trauma. D. Stimulate venous return.
D. Stimulate venous return.
Your patient was admitted to the hospital 3 days ago with cardiac problems and now has bacterial pneumonia. This is an example of what type of infection?
Health care-associated (nosocomial)
Today the nurse is assigned to care for a patient who has tuberculosis. What equipment should the nurse routinely use when caring for this patient?
N-95 respirator
Health care providers today need to be aware that health care-associated infections are a serious problem. What is the most effective way to prevent health care-associated infections?
Perform proper hand hygiene before and after caring for a patient
What steps are included in assessment of pain?
SOCRATES site, onset, character, radiation, associated signs and symptoms, time pattern, exacerbating/relieving factors, and severity
The adult patient is seen in the 24 hr medicenter for heat exhaustion. The nurse anticipates that treatment will include which of the following? a. fluid replacement b. antibiotic therapy c. hypothermia wraps d. tepid water baths
a. fluid replacement
The patient is experiencing pain and asks for medication, which has been ordered by the provider. The nurse first assess the vital signs and finds them to be: blood pressure 144/82, pulse 88/min, and respiration 24/min. The nurse should: a. give the medication as ordered b. check again that the patient has pain c. withhold the medication d. wait 20 minutes and check the vital signs again before giving the medication
a. give the medication as ordered
A primary concern for a patient with orthostatic hypotension is the: a. risk of injury b. fluid overload c. oxygen demand d. mental confusion
a. risk of injury
The nurse documents Cheyne-Stokes respiration for the patient who has which of the following? a. rhythmic respiration, from very deep to very shallow to apneic periods b. abnormally deep and rapid respiration c. shallow, slow respiration d. shallow, rapid respiration
a. rythmic respiration, from very deep to very shallow to apneic periods
For a 72 yr old patient, which of the following vital sign measurements is within the expected range? a. BP 80/40, P 110, R 40 b. BP 100/70, P 72, R20 c. BP 84/60, P 80, R 26 d. BP 90/60, P 110, R 16
b. BP 100/70, P 72, R 20
The nurse has taken vital signs on a 34 yr old patient. Which of the following findings should be reported as outside of the expected range for this age group? a. T 98F b. P 140 bpm c. R 22/min d. BP 120/78
b. P 140 bpm
A teenage patient with the flu is febrile and needs the body temperature reduced. The nurse anticipates that treatment will include which of the following? a. ice packs to the axilla and groin b. a cooling blanket c. an ice water bath d. aspirin
b. a cooling blanket
A patient comes to the emergency department after having been in the sun all day. The nurse also determines that the patient is taking a diuretic. Heat stroke is suspected, and the nurse observes for which of the following? a. diaphoresis b. confusion c. temperature of 35 to 37 C d. decreased heart rate
b. confusion
Which of the following are signs of hyperthermia (fever)? a. bradypnea b. malaise c. pale skin d. shivering e. decreased muscle coordination f. tachycardia
b. malaise d. shivering f. tachycardia
52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant: a) temperature b) radial pulse c) respiratory rate d) oxygen saturation
c) respiratory rate
A patient asks the nurse about whether her blood pressure is too high. The nurse informs the patient that the blood pressure associated with stage 1 hypertension is: a. 120/70 b. 130/80 c. 140/90 d. 160/110
c. 140/90
For a patient who needs the blood pressure measured in the lower extremities, the nurse knows that the measurement will be: a. the same as the upper extremity b. 20 mm Hg lower than in the brachial artery c. 20 mm Hg higher than in the brachial artery d. 40 mm Hg higher than in the brachial artery
c. 20 mm Hg higher than in the brachial artery
The patient has abdominal surgery this morning. When the nurse checks the vital signs, the findings are as follows: BP 110/60, P 110, and R 32/min. What should the nurse do first? a. Retake the vital signs in 15 min b. continue with care as planned c. check the surgical dressing d. administer the medication for pain
c. check the surgical dressing
Identify which of the following can cause tachycardia. Select all the apply a. hypothermia b. head injury c. fever d. hypoxia e. stress d. use of beta-blocker meds
c. fever d. hypoxia e. stress
The patient gets out of bed to go to the bathroom and tells the nurse that he "feels dizzy." The nurse should first: a. go for help b. take the blood pressure c. help the patient to sit down d. have the patient take deep breaths
c. help the patient sit down
which of the following factors will result in a decrease in a patient's blood pressure? a. pain b. head injury c. hemorrhage d. use of oral contraceptives
c. hemorrhage
The patient has difficulty seeing and is complaining of pain. It is most appropriate to use which of the following pain scales? a. faces scale b. a large print faces scale c. numeric pain assessment scale d. multiple language pain assessment scale
c. numeric pain assessment scale
Where is the correct location for the temporal artery temperature measurement?
center of the forehead and then moved across to the hairline by the temple. If there is perspiration present, the probe should be touched to the skin behind the earlobe over the mastoid process
When measuring vital signs, the nurse is aware that blood pressure is usually lower in the presence of or following: a. anxiety b. exercise c. cigarette smoking d. diuretic administration
d. diuretic administration
On entering the room, the nurse observes that the patient appears to be tachypneic. The nurse should: a. ask if there have been visitors b. have the patient lie flat c. take the radial pulse d. measure the respiratory rate
d. measure the respiratory rate
The patient has been on the floor for 2 days with a diagnosis of asthma. She has been stable and her discharge is planned for tomorrow. She uses her call bell and complains of feeling anxious but denies difficulty breathing and cannot verbalize the cause of her anxiety. Which of the following would be the best intervention at this point? a. check the electronic record to see if she has an order for an anti anxiety medication b. reassure her that she is probably anxious about being discharged tomorrow c. check her temperature to make sure she does not have an infection d. perform a pulse oximetry measurement
d. perform a pulse oximetry measurement
The nurse instructs the aide that a falsely low blood pressure reading will be obtained by which of the following methods? a. using a cuff that is too narrow b. releasing the pressure valve too slowly c. assessing the blood pressure after the patient exercises d. placing the arm above the level of the heart
d. placing the arm above the level of the heart
Which side of the dual head is used for higher-pitched sounds?
diaphragm
To prevent hypothermia in an older adult patient, the nurse instructs the patient to do what?
dress in layers use a blanket wear scarf and gloves and hat keep extremities covered keep thermostat at 68F
Which factors can lead to hypoventilation
drug overdose, obesity, COPD, cervical spine injury
What are nonverbal indications that a patient is experiencing pain?
grimacing, pulling away from touch, changes in vital signs, agitation, and restlessness
When are rectal temperatures contraindicated?
newborns and patients with neuropenia, spinal cord injuries, diarrhea, rectal disease/surgery, and quadriplegia
What is the pulse used for blood pressure measurement in the lower extremity?
popliteal pulse
