Dynamic questions/Fundies Book questions -BP/VS/Resp/ROS

A nurse is instructing an assistive personnel (AP) about caring for a client with low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?

"Do not measure the client's temperature rectally"

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect?

- tooth loss - glare intolerance - thickened eardrums

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify outside the expected range?

BP 140/90 mmHg

After assessing a client's radial pulses, the nurse document's "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?

Bounding

A nurse is caring for a client who has a terminal illness. Which of the following findings indicate that the client's death is imminent?

Cold extremities

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

Dorsalis pedis

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfussion?

Perform a blanch test

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V?

- Clench your teeth -Tell me when you feel a touch

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include?

- Place the client in semi-Fowler's position - Have the client rest an arm across the abdomen - Observe one full respiratory cycle before counting the rate

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure

116/70 mmHg

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit (per minute)?

16 The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points 84-68= 16

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?

Ask the client if they are having pain

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing pain medication.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse

a nurse is caring for a client who was transferred to the surgical unit by stretcher from the PCU. Which of the following actions should the nurse perform immediately following the transfer?

Check the client's vital signs

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the patients pail level

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the reading are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

Grimacing

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate

A client who reports shortness of breath requests the nurses's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

A nurse is caring for a client who has dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in lateral position with the head turned to the side before beginning the procedure.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

A nurse is measuring a client's vital signs. The client's heart rate is 105/m. The nurse should document this finding as which of the following alterations?

Tachycardia

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2C (102.6D), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?

Temporal

A nurse is provider nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use a pain scale to determine the client's pain level

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

Using a cuff that is too small will result in an inaccurately high reading

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

What do you think caused the onset of your pain?

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect?

crackles in the lung fields

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

"Your eyes see at a 20 feet when visually unimpaired eyes see at 30 feet"

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect?

- Palpating the thyroid in the lower half of the neck - Feeling the thyroid ascend as the client swallows - Finding symmetric extension off the trachea on both sides of the midline

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take?

- Place the client in supine position with the hips and knees flexed - Cover the wound and intestine with a sterile, moistened dressing - Monitor the client for manifestations of shock

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take?

- insert the speculum slightly down and forward - make sure the speculum does not touch the ear canal - use the light to visualize tympanic membrane in a cone shape

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3C (101F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take?

- obtain culture specimens before initialing antimicrobials - encourage the client to rest and limit activity

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

Decreased cardiac output

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response?

Increased blood pressure

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis