HAP Quiz 9

The nurse has assessed the patients on the unit. Which patient should be attended to first? A. Patient who had a stroke 5 years ago and presently has 5/5 strength in all extremities. B. A patient with a heart rate of 84 beats per minute and oxygen saturation of 99% C. A patient with blood pressure of 180/110 mm Hg and urine output of 20 mL/hr D. A patient with a respiratory rate of 16 breaths per minute and temperature of 98.6 F

A patient with blood pressure of 180/110 mm Hg and urine output of 20 mL/hr

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report? A. I'm concerned that his gastrointestinal bleeding is getting worse. B. My name is Mr Hope, and I'm giving report on Mrs X in room 1045. C. We need and order for oxygen. D. He is 4 days postoperative, and his incision is open to air.

He is 4 days postoperative, and his incision is open to air.

A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A. IX, X B. IX, XII C. X, XII D. XI, XII

IX and X

At the beginning of rounds when entering the room, what would the nurse do first? A. Check the intravenous(IV) infusion site for swelling or redness B. Check infusion pump setting for accuracy C. Make eye contact with the patient, and introduce themself as the patient's nurse D. Offer patient something to drink

Make eye contact with the patient, and introduce themself as the patient's nurse

The nurse is conducting a cultural assessment for a new patient. This is important to ensure that: A. the nurse can communicate with the family. B. the patient has access to the appropriate chaplain. C. the nurse can avoid making assumptions. D. the patient can get the proper dietary nutrients.

the nurse can avoid making assumptions.

Which data does a nurse collect during the general inspection? (SELECT ALL THAT APPLY) A. Muscle strength B. Gait C. Breath sounds D. Heart sounds E. Mood or affect F. Hearing and speech abilities

Mood or affect Gait Hearing and speech abilities

During the assessment, the nurse determines that the patient's Glasgow Coma Scale score is 15. What is the meaning of this number for this patient? A. This patient opens the eyes but does not speak or move. B. This patient is fully conscious. C. This patient is unable to respond to any stimuli. D. This patient has movement but does not open the eyes or speak.

This patient is fully conscious.

During auscultation of breath sounds, the examiner should: A. only listen to the posterior chest for adventitious sounds. B. listen with the bell of the stethoscope. C. instruct the patient to breathe in and out through the nose. D. compare sounds on the left and right side.

compare sounds on the left and right side.

How does a nurse assess perfusion to the foot when a patient has a cast from the left middle calf to the toes? A. Palpate the popliteal pulse of the left leg. B. Assess movement and sensation of the left toes. C. Assess the capillary refill of the left toes. D. Palpate the posterior tibial pulse of the left leg.

Assess the capillary refill of the left toes.

When does the health assessment begin? A. When the patient tells the nurse his name and age B. When the patient consents to have a health assessment performed C. When the nurse first meets the patient D. When the nurse asks the patient the first health-related question

When the nurse first meets the patient