Intro: Exam 1
which action should the nurse perform after identifying a pulse deficit A. reassess the apical-radial pulse for 5 minutes B. assess the patient for signs of decreased cardiac output C. notify the primary health care provider of the pulse deficit D. initiate interventions directed toward managing the patient's symptoms
B. assess the patient for signs of decreased cardiac output
which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment? A. take the patient's temp while counting the RR B. assess the respirations after measuring the pulse C. assess the respirations after taking the blood pressure D. assess the respirations before measuring the blood pressure
B. assess the respirations after measuring the pulse
A client suffering from ______ may have decreased fremitus, dull percussion over the affected area, and crackle sounds upon auscultation like A. Asthma B. atelectasis C. pneumonia D. pleural
B. atelectasis
Which step in the research process is similar to the assessment step of the nursing process? A.Developing the hypothesis B.Identifying the problem C.Analyzing the results D. Conducting the study
B. identifying the problem
what would the nurse do first when preparing to begin oxygen therapy for a patient? A. educate the NAP about oxygen orders B. review the medical prescription for delivery method and flow rate C. place a "No smoking" signs outside of the hospital room D. Ensure that suction equipment is present in the room
B. review the medical prescription for delivery method and flow rate
where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy? A. use the left arm to take the blood pressure B. use the right arm to take the blood pressure C. do not take the blood pressure D. use a lower extremity to take the blood pressure
B. use the right arm to take the blood pressure
Jonathan is speaking to Mr. Smith. Mr. Smith is gesturing animatedly, and Jonathan is facing him, leaning slightly forward with his hands at his sides, making steady eye contact while he smiles and mods in response to Mr. Smith's words. What is Jonathan's body language conveying? A. Attentiveness B. Aggression C. Boredom D. Impatience
A. Attentiveness
The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply. A. Encourage turning, coughing, and deep breathing exercises B. Perform frequent breath sounds assessment C. Decrease by mouth fluid intake D. Offer a high-potassium diet E. Obtain a chest x-ray
A. Encourage turning, coughing, and deep breathing exercises B. Perform frequent breath sounds assessment
A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? A.Evaluation B.Assessment C.Planning D.Implementation
A. Evaluation
What is the part of the brain that most closely associated with empathy? A. Limbic system B. Neocortex C. Medulla D. Cerebellum
A. Limbic system
sarah asks a patient how she is feeling and gets a cheery "I'm fine." Sarah notes that the patient's smile looks forced, her posture is hunched, and she is rubbing her knee. What would Sarah do next? A. Accept the patient's statement. She is probably fine and Sarah has a lot of work to get through today B. Investigate further. The patient's words and actions appear to contradict each other C. Maintain silence and hope the patient will choose to share additional information D. Make a note of her observations, but avoid challenging the patient. She obviously does not want to talk about it.
B. Investigate further. The patient's words and actions appear to contradict each other
The thomas-Kilamn conflict management style that is usually the most effective is A. Accommodating B. Avoiding C. Collaborating D. Competing
C. Collaborating
when preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimizing the patient's risk for injury? A. place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room B. Instruct NAP to immediately correct or report safety hazards C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method
C. inspect all electrical equipment in the patient's room for the presence of safety-check tags
when a patient is receiving oxygen therapy at home, which instructions to the family would help them understand how to use the oxygen safely? A. increase the oxygen level as needed for the patient's comfort B. store extra oxygen cylinders horizontally c. place a "no smoking" sign at the entrance to the house D. keep oxygen 5 feet (about 1.5 meters) from anything that could generate a spark
C. place a "no smoking" sign at the entrance to the house (levels should not be adjusted, cylinders should be stored vertically, and keep 10 feet away)
Client with increased fremitus over the affected area, dull percussion over the affected area, and bronchial sounds upon auscultation may have A. Asthma B. atelectasis C. pneumonia D. pleural effusion
C. pneumonia
what would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? A. evaluate the patient's understanding of the combustible nature of oxygen B. Arrange for a capable family member to be present during the initial discussion C.collect written information to present to the patient as a supplemental instructional materials D. assess the patient's emotional readiness and physical ability to provide autonomous care
D. assess the patient's emotional readiness and physical ability to provide autonomous care (this is important to assess before you can educate the patient)
When caring for a patient whom oxygen by nonbreathing mask has been ordered, which action ensures appropriate oxygen delivery? A. Looping the oxygen tubing around the side rail of the bed B. Assessing breath sounds every shift C. Securing the tubing snugly to the patient's gown D. Assessing that the reservoir bag stays inflated
D. assessing that the reservoir bag stays inflated
When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? A. Frequently asking the patient how he or she is breathing B. Ensuring the oxygen tubing is pulled tight, with little to no slack C. securing the oxygen tubing to the patient's clothing to prevent tugging D. Assessing for proper placement of the mask on the patient's face
D. assessing the proper placement of the mask on the patient's face
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient's respiratory rate? A. count breaths for 10 seconds then multiply by 6 B. count breaths for 15 seconds then multiply by 4 C. count breaths for 30 seconds then multiply by 2 D. count breaths for 60 seconds
D. count breaths for 60 seconds.... because 10 is below range, you need to count for a full 60 seconds to be most accurate
what is the major health problem resulting from a pulse deficit? A. bradycardia B. Activity intolerance C. decreased cardiac output D. impaired tissue perfusion
c. decreased cardiac output
what mask is a nonrebreather mask
one with the bag attached
what mask provides 35%
venturi mask
Decreased chest wall movements, hyperresonance, and wheezing indicate A. Asthma B. atelectasis C. pneumonia D. pleural effusion
A. asthma
which of the following is an early manifestion of decreased cardiac output? A. fatigue B. substernal pain C. Nail bed cyanosis D. Shortness of breath
A. fatigue
what type of question promotes more complete answers? A. Close-ended B. open-ended C. reflective D. Leading
B. Open-ended
a client with increased vibrations over the chest wall above effusion, dull percussion, and diminished or absent breath sounds over the affected area may have A. Asthma B. atelectasis C. pneumonia D. pleural effusion
D. pleural effusion
Mrs. Carson is frowning, has her arms crossed over her chest, and is looking at her watch as she waits for her turn. What is her body language conveying? A. anger B. Boredom C. Happiness D. Impatience
D. Impatience
Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? A. To provide the correct amount of oxygen to the patient B. To ensure the therapeutic effects of oxygen therapy C. To prevent any adverse reaction to the prescribed oxygen therapy D. to minimize the risk of combustion during oxygen delivery
A. to provide the correct amount of oxygen to the patient
The nurse assesses for what client symptoms that indicate hyperthermia? Select all that apply. a. Vasodilation b. Dry and flushed skin c. Pale and cyanotic skin D. Decreased capillary refill E. Decreased urinary output
A. vasodilation B. dry and flushed skin E. Decreased urinary output
The registered nurse teaches the student nurse about the care of clients with frostbite. Which priority intervention performed by the student nurse indicates effective learning? A. Administering analgesics B. Warming the frostbite area in water bath C. Elevating the area above heart level D. Applying a loose, nonadherent sterile dressing
B. Warming the frostbite area in water bath
While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? Select all that apply. A. Poor fitting of the cuff B. Inflating the cuff too quickly C. Deflating the cuff too quickly D. Inflating the cuff inadequately E. Applying the stethoscope too firmly
A. poor fitting of the cuff C. Deflating the cuff too quickly
What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? A. Regularly measure and trend the patient's pulse oximetry (SpO2) values B. Evaluate venous blood levels every morning C. Monitor the patient's arterial blood gas (ABG) levels hourly D. Assess the patient for compliance with the prescribed therapy
A. regularly measure and trend the patient's pulse oximetry (SpO2) values
What are the signs and symptoms observed in the human body with a decrease in body temperature? Select all that apply. A. Shivering B. Profuse sweating C. Flushed appearance D. Dilation of blood vessels E. Contraction of blood vessels
A. shivering E. contraction of blood vessels
what is the primary step in forming an empathetic relationship? A. Showing interest B. Displaying authenticity C. Withholding judgement D. Active listening
A. showing interest
Which body temperature measurement sites would be considered safe, inexpensive, and least invasive? Select all that apply. A. Skin B. Oral C. Axilla D. Rectal E. Tympanic
A. skin C. Axilla
inadequate oxygenation to the body will cause the radial pulse to become: A. tachycardiac B. bradycardiac C. Irregular D. Bounding
A. tachycardiac (the heart rate will increase to circulate more available oxygen to the tissues)
Keri is listening to Mrs. Ellison. they have found a quiet place for their conversation and Keri leans towards Mrs. Ellison and makes eye contact as they talk. By doing this, Keri is performing which part of active listening? A. Giving her full attention B. Encouraging Mrs. Ellison to elaborate on her statement C. Communicating her understanding D. Waiting for Mrs. Ellison to stop talking so she can speak
A. Giving her full attention
An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 105° F. Which condition does the nurse suspect in the client? A. Heat stroke b. Heat exhaustion c. Accidental hypothermia d. Malignant hyperthermia
A. Heat stroke
An injured client with an open wound is brought to the hospital. The doctor asks the nurse to administer a tetanus toxoid injection. Which step of the nursing process does the nurse follow next? A.Implementation B.Diagnosis C.Evaluation D.Assessment
A. Implentation (the nurse hasn't done the action of giving the shot. If the nurse had already given the shot, then the answer would be evaluation)
Which statement appropriately describes tidal volume? A. It is the volume of air inhaled and exhaled with each breath. B. It is the amount of air remaining in the lungs after forced expiration. C. It is the additional air that can be forcefully inhaled after normal inhalation. D. It is the additional air that can be forcefully exhaled after normal exhalation.
A. It is the volume of air inhaled and exhaled with each breath.
The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? A. Prolonged exhalation to decrease air trapping B. Shortened inhalation to reduce bronchial swelling C. Increased respiratory rate to improve arterial oxygenation D. Decreased use of diaphragm to increase amount of inspired air
A. Prolonged exhalation to decrease air trapping (get rid of more CO2)
A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? A. The client may have a dysrhythmia B. The client may have physiologic shock C. The client underwent surgery earlier in the day D. The client may have peripheral artery disease
A. The client may have a dysrhythmia
When is the compromising conflict resolution style most effective? A. When all parties are happy with the solution B. When neither party is required give too much up to gain what they needed C. When there are no other choices D. When the outcome could be much worse
A. When all parties are happy with the solution
When is it advisable to actively work to resolve a minor workplace conflict? A. When it could prevent a bigger problem from forming B. When it involves an important person C. Only if most people agree that it should be handled D. It is never advisable to try to resolve a minor workplace conflict
A. When it could prevent a bigger problem from formin
a communication technique where the listener gives the speaker her full attention in order to understand, respond, and remember what was said is called? A. active listening B. Listening C. Reflective listening D. Nonverbal communication
A. active listening
A doctor asks a nurse to collect the medical history of a client. What nursing process should the nurse undertake? A.Assessment B.Planning C.Implementation D.Diagnosis
A. assessment
which of the following is a risk factor for decreased pxygen saturation level in a patient? A. Chest wall injury B. Restlessness C. Hypotension D. Prescribed bronchodilations
A. chest wall injury
Jeremy has identified a workplace conflict. Using the steps of conflict resolution, what should Jeremy do next? A. determine if the conflict is worth addressing B. Invite input C. Look for common ground D. Seek solutions that consider all viewpoints and achieve common goals
A. determine if the conflict is worth addressing
After assessing a dark-skinned client, the nurse concludes that the client has cyanosis. Which assessment color variation helped the nurse reach this conclusion? A. Grey color B. Purple color C. Dark red color D. Purple-to-brownish color
A. grey color
A patient is prescribed continuously oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? A. Low of 85% and high of 100% B. Low of 80% and high of 100% C. Low of 75% and high of 90% D. Low of 82% and high of 95%
A. low of 85% and high of 100%
Which action would best assess the effect of exercise on a patient's radial pulse measurement? A. measuring the patient's radial pulse before and after exercise B. assessing the patient's radial pulse 30 minutes after exercise C. Comparing the patient's radial and apical pulse after exercise D. Comparing the patient's pre-exercise radial and post-exercise apical
A. measuring the patient's radial pulse before and after exercise
when measuring a patient's RR, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? A. the number of inspirations and expirations per minute B. the number of expirations per minute C. the number of sighs per minute D. the number or inspirations per minute
A. the number of inspirations and expirations per minute
What is empathy? A. Sharing the feelings of others B. The ability to understand the feelings of others C. The total impression you make on people through your behavior, body language, and charisma D. Knowing how to appropriately behave in a particular situation
B. The ability to understand the feelings of others
What should the nurse teach NAP about selecting the appropriate site for measuring a patient's oxygen saturation level? A. "Do not use the fingers if her nails are polished" B. "I've checked her capillary refill, and it's acceptable in both her hands and feet" C. "Please review the patient's previously documented pulse oximetry readings for the site used" D. "Ask the patient to keep her fingers motionless while you are monitoring her oxygen saturation"
B. "I've checked her capillary refill, and it's acceptable in both her hands and feet"
Crystal had a terrible morning. Her car had a flat and she would have been late for work if one of her neighbors hadn't helped her change it. She arrives at work looking a little rattled, worrying about getting her tire fixed, and Jenna, a coworker she is friendly with, ask how she is. Which response would be the most appropriate? A. "I'm fine" B. "My car had a flat tire this morning. I'm really glad I wasn't late. We have so much to do today. I'll tell you about the rest after work" C. "You won't believe this. When I went outside this morning, on of my car tires was completely flat. I think it was that punk down the street. But then-and this is the good part of the whole thing- my hot neighbor from next door sees me looking at the tire and comes out of his house and changes it for me. I'm going to take him out for a drink tomorrow to thank him." D. I don't want to talk about it. After the way it started, I can't wait for his day to be over"
B. "My car had a flat tire this morning. I'm really glad I wasn't late. We have so much to do today. I'll tell you about the rest after work"
you have the following vitals: oral temp- 36.8C radial pulse- 112, weak, thready apical pulse- 117 regular respirations- 24 regular blood pressure- 104/56, right arm 102/50, left arm what is the pulse deficit? A. 2 B. 5 C. 6 D. 48
B. 5
what is the nurse's priority action if a patient's radial pulse has an irregular rhythm? A. reassess the pulse for 1 full minute B. Assess the patient for a pulse deficit C. Wait 5 minutes, and then reassess the pulse D. Review documentation regarding an irregular rhythm
B. Assess the patient for a pulse deficit (key word: irregular. no need to check it again, but need to look for other complications that can be causing irregular rhythm)
the nurse is preparing to assess a patient's blood pressure. What would cause the blood pressure reading to be inaccurately high? A. blood pressure cuff is too wide B. Blood pressure cuff is too loose around the arm C. Taking the blood pressure in an arm into which intravenous fluids are infusing D. Arm is positioned above the level of the heart
B. Blood pressure cuff is too loose around the arm
Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? A. Apply a thoracic binder for support. B. Encourage coughing and deep breathing. C. Defer pain medication the first day after injury. D. Position the client face-down on a soft mattress.
B. Encourage coughing and deep breathing.
The nurse plans to assess a patient's RR; however the patient has just returned from ambulating to the bathroom. what should the nurse do to minimize the effect of exercise on the patient's RR? A. assess the pulse for a full 60 seconds before assessing respirations B. Encourage the patient to rest for 10 minutes before assessing respirations C. compare the post-exercise RR with his baseline findings D. compare the post-exercise findings with the previous at-rest findings
B. Encourage the patient to rest for 10 minutes before assessing respirations
During the admission process, the nurse initially assess the patient's radial pulse primarily for what purpose? A. assessment of peripheral blood perfusion B. Establishment of a baseline as part of the patient's vital signs C. Assessment of the patients cardiovascular disease risk D. Determination of oxygen saturation
B. Establishment of a baseline as part of the patient's vital signs
What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? A. arterial blood gas (ABG) levels B. Oxygen flow meter setting C. Respiratory rate D. Temperature
B. Oxygen flow meter setting
which of the following is contraindicated with taking a rectal temp? A. patient requires assistance to move to a side-lying position B. Patient has painful and swollen hemorrhoids C. Patient is incontinent or urine D. The last temp recorded was 0.2F above baseline
B. Patient has painful and swollen hemorrhoids
Place the steps of the nursing process in its correct order. A.Define the nursing diagnoses or collaborative problems clearly. B.Plan the care by determining priorities, goals, and expected outcomes of care. C.Identify the client's health care needs by collecting subjective and objective data. D.Perform the nursing interventions competently. E. Evaluate the effects of the nursing interventions performed.
C, A, B, D, E
which statement by the patient would indicate that he or she understands the safe use of oxygen? A. "the nurse told me that my oxygen saturation must be maintained at 85% or above" B. "I know that oxygen is a medication I can adjust whenever I need to" C. "I'll alert the nurse immediately if i have any increased difficulty breathing" D. "I often experience difficulty breathing for no apparent reason, but that is expected"
C. "I'll alert the nurse immediately if i have any increased difficulty breathing"
Which client body temperatures are indicative of moderate hypothermia? Select all that apply. A.80° F (26.7° C) B. 84° F (28.9° C) C. 88° F (31.1° C) D. 92° F (33.3° C) E. 96° F (35.6° C)
C. 88° F (31.1° C) D. 92° F (33.3° C)
which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temp of 101.6F? A. assess for physical aches B. Assess skin temp by touching the forehead C. Assess oral temp 30 minutes after the agent is administered D. Assess skin color for signs for fever-related flushing
C. Assess oral temp 30 minutes after the agent is administered
When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula B. Removing the cannula every 2 hours for no longer than 10 minutes C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift D. Instructing the patient to inform staff of any problem with facial dryness or cracking
C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? A. Decrease in red cell formation B. Rupture of emphysematous bullae C. Depression in the respiratory center D. Excessive drying of the respiratory mucosa
C. Depression in the respiratory center
which of these people is displaying the most attentive body language? A. Lia flips through the medical record and takes notes while Mrs. Rush explains her medical history B. John makes eye contact with Mr. Smith frequently as he types at his workstation and nods at one of his comments to show he is paying attention C. Elaine puts her papers down and sits down across from Mr. Klein, hands in her lap, and makes eye contact with him while he explains his situation D. Thomas listens to Ms. Brown while he works at making her comfortable, occasionally smiling or glancing her way
C. Elaine puts her papers down and sits down across from Mr. Klein, hands in her lap, and makes eye contact with him while he explains his situation
which instruction might the nurse give to the NAP that is applicable only to tympanic temperature assessment? A. Leave the probe in place until the reading is complete B. Put on a new disposable probe cover for each patient C. Gently tug the pinna backward, up, and out before inserting the probe D. check for any impacted cerumen in the ear
C. Gently tug the pinna backward, up, and out before inserting the probe
how does active listening result in better patient care? A. active listening causes patients to be more compliant with their treatments B. Active listening demonstrates resspect C. Health care professionals with good listening skills are able to uncover valuable information that can be used to provide better care D. Patients value providers who are good listeners
C. Health care professionals with good listening skills are able to uncover valuable information that can be used to provide better care
The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? A. Recording the volume of the air inspired B. Performing 10 breaths per session every hour C. Inhaling air fully before inserting the mouthpiece D. Taking a long, slow, deep breath keeping the mouthpiece in place
C. Inhaling air fully before inserting the mouthpiece
the nurse has just measured a patient's blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements? A. minimize the effect of anxiety B. distract the patient C. Listen for the second and third Korotkoff sounds D. Confirm that the cuff was applied correctly
C. Listen for the second and third Korotkoff sounds
Two of Patricia's employees have been chronically arguing over an aspect of patient care and Patricia is getting complaints from other employees, and patients who has been left waiting. Patricia has described that this problem needs to be addressed because it is having a negative effect on patients and healthcare providers. Using the steps of conflict resolution, what should Patricia do next? A. Focus on the issues and avoid personal attacks on the indivuals involved B. Invite everyone's input through collaboration C. Look for common ground. What can the parties agree on? D. Seek solutions that consider all viewpoints and achieve common goals
C. Look for common ground. What can the parties agree on
Focusing your attention on the present, observing your environment, and accepting without judgement are aspects of which empathy-building practices? A. Active listening B. Loving-Kindness meditation C. Mindfulness meditation D. Primordial sound meditation
C. Mindfulness meditation
What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? A. advising the patient to call for assistance before getting out of bed B. Instructing NAP to immediately correct the flow rate if the oxygen regulator is not set as prescribed C. Observing the six rights of medication administration D. Monitoring the patient for signs of hypoxia
C. Observing the six rights of medication administration
which instruction might the nurse give to the NAP that is applicable ONLY to temporal artery temp assessment? A. an acurate temp reading is obtained with moisture on the forehead B. Put on a disposable sensor cover before taking the temporal artery temp C. Place the sensor flush on the patient's forehead D. Obtain the temp reading on the lower neck
C. Place the sensor flush on the patient's forehead
Brandon takes Mr. Jone's blood pressure and cheerfully announces "BP is 120 over 80." Mr. Jones appears confused. This is an example of? A. Being too familiar C. Oversharing C. Using jargon D. Using unprofessional language
C. Using jargon
What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? A. Scoliosis B. Kyphosis C. Clubbing D. Kyphoscoliosis
C. clubbing
what should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? A. encourage oral fluids B. Restrict fluids C. Ensure that humidification is present D. Measure blood pressure every hour
C. ensure that humidification is present
When caring for a patient who is receiving supplemental oxygeb by face tent, which action ensures that oxygen is flowing? A. testing the closing capacity of the mask's valves B. Routinely monitoring the seal over the patient's mouth and nose C. Ensuring that a mist is always present D. Regularly verifying that the mask is positioned loosely
C. ensuring that a mist is always present
What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? A. Encourage the patient to take a deeper breaths in order to get more oxygen B. Change the device from nasal cannula to simple face mask C. Ensure that humidification is present D. Adjust the float ball on the flow meter to 3 L/min
D. adjust the float ball on the flow meter to 3 L/min
An accurate nursing diagnosis includes A. Diagnostic label/ NANDA approved nursing diagnosis B. Related factor (when applicable) based on assessment data tat detests the etiology/pathophysiology of the problem C. Symptoms or defining characteristics: objective and subjective data support your diagnosis D. all the above
D. all the above
the nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions? A. follow your regular healthy diet B. Limit physical activity C. Ensure an adequate daily intake of sodium and fat D. ensure that your diet has an adequate daily intake of calcium
D. ensure that your diet has an adequate daily intake of calcium
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? A. Face tent B. Venturi mask C. Nasal cannula D. Nonrebreather mask
D. nonrebreather mask
what would cause the nurse to delay the assessment of a patient's blood pressure? A. patient is resting in bed, reading a book B. patient received medication within the last 10 minutes C. patient is visiting with family D. patient has just finished having a cigarette
D. patient has just finished having a cigarette
A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg? A. 130/80 mm Hg B. 150/100 mm Hg C. 140/100 mm Hg D. 130/100 mm Hg
D. 130/100 mm Hg (deflating too fast could result in false low systolic and false high diastolic)
what should the nurse do when a pulse deficit is suspected? A. measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute B. measure the radial pulse for 30 minutes and then measure the apical pulse for 30 seconds C. measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute D. Ask another health care provider to count the radial pulse while the nurse counts the apical
D. Ask another health care provider to count the radial pulse while the nurse counts the apical
The nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? A. Reassess the oxygen saturation in a different location B. Promptly report the assessment data to the charge nurse C. Encourage the patient to rest quietly in bed for 30 minutes D. Ask the patient whether he or she is having trouble breathing
D. Ask the patient whether he or she is having trouble breathing
during the assessment of a patient's RR, when the second hand reaches the 15 second mark, the respiratory count was 8. what should the nurse do at this time? A. stop the assessment B. stop the assessment, and multiply by 2 C. stop the assessment, and multiply 8 by 6 D. Continue to count the patient's breaths for a full 60 seconds
D. Continue to count the patient's breaths for a full 60 seconds
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? A. Productive cough B. Clubbing of the fingertips C. Crackles at the height of inhalation D. Diminished breath sounds on auscultation
D. Diminished breath sounds on auscultation
While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this? A. Provide comfort to the client B. Minimize trauma to rectal mucosa C. Reduce transmission of microorganisms D. Ensure adequate exposure to the blood vessels
D. Ensure adequate exposure to the blood vessels
While obtaining the vital signs of a client, the nurse finds that the body temperature of the client is 98.6 °F. The nurse concludes that the client is experiencing what? A. Hypothermia B. Hyperpyrexia C. Hyperthermia D. Normothermia
D. Normothermia
what will the nurse instruct the NAP to do when measuring an adult patient's radial pulse? A. place the patient in the lateral (side-lying) position before measuring the pulse B. apply gloves with each patient before measuring the pulse C. Document whether the patient's pulse is bounding or has diminshed D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers
D. Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers
The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what? A. Renal function B. Cardiac output C. Oxygen saturation D. Peripheral vascular resistance
D. Peripheral vascular resistance
The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? A. Skin B. Oral C. Axilla D. Rectal
D. Rectal
The nurse is preparing to measure the oxygen saturation level of patient with obesity. Which action would help ensure an adequate measurement? A. Place the sensor on the ear B. Place the sensor on the bridge of the nose C. Place the sensor on a finger D. Use a disposable tape-on sensor
D. Use a disposable tape-on sensor
what will the nurse instruct the NAP to do when measuring a patient's rectal temp? A. place the patient in fowler's position B. wear sterile gloves during the process C. Insert the probe in the direction of the knees D. Use the probe with the red tip
D. Use the probe with the red tip (the patient should be laying on left side sims, sterile gloves aren't necessary but clean gloves are)
