Chapter 28 (Kozier and Erb's)

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery

1

The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72. 2. 72/136. 3. 136 72. 4. 72 136.

1

What is the first thing that the nurse should do to ensure an accurate temperature reading for a client? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

1

What will the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound

1

When assessing a clients blood pressure, the nurse will use which artery? 1. Brachial 2. Femoral 3. Radial 4. Ulnar

1

When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color

1

When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX. 2. O. 3. R. 4. SL.

1

When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in: Standard Text: Select all that apply. 1. Oxygen concentration. 2. Carbon dioxide concentration. 3. Hydrogen ions. 4. Potassium level. 5. Serum calcium level.

1,2,3

When assessing the pulse of a client, the nurse will include which characteristics? Standard Text: Select all that apply. 1. Rate. 2. Rhythm. 3. Volume. 4. Tone. 5. Viscosity.

1,2,3

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments himself on which clients? Standard Text: Select all that apply. 1. Client complains of chest pain. 2. Client returning from surgery. 3. Prior to administering a medication that affects blood pressure. 4. Client complains of dizziness after ambulating. 5. Client being admitted to the care area.

1,2,3,4

Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress. 2. Race. 3. Obesity. 4. Medications. 5. Employment.

1,2,3,4

A client in a motor vehicle crash has arrived at the trauma unit in respiratory distress and unconscious. Which factor would cause a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress

2

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress

2

Which of the following positions does the RN assist the client in to best assess respiratory status? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine

2

Which of the following sites would be the most appropriate choice to use to measure a clients temperature who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago? 1. Axilla 2. Oral 3. Popliteal 4. Rectal

2

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt

3

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which of the following nursing interventions would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and just try again later.

3

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower room temperature.

3

A client is being treated for congestive heart failure. Which of the following physical findings would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes

4

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to: 1. Anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted.

4

As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What would be the next action taken by the RN? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen.

4

The nurse is going to assess the apical-radial pulse off a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

4

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch

4

Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance

4

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site.

4