Fundamentals Quiz 2 Question Review
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 98.8, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
BP
Fowler's position is a bed position:
In which the head and trunk are raised 45-60 degrees.
A nurse assesses orthostatic hypotension in an older adult. What would be an appropriate intervention for the patient?
Allow the patient to "dangle" for a few minutes prior to rising to a standing position.
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Asses the apical pulse for a full minute.
A nurse is planning a seminar on secretions and coughing. Which of the following describes a condition in which blood is present in sputum?
Hemoptysis
A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?
Inner ankle
A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultation the client's apical pulse.
Left side of the chest
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheels of the bed and the wheelchair.
A nurse assesses an oral temperature for an adult patient and records that the patient is afebrile. What would be the nurse's best response to this finding?
No action is necessary; this is a normal reading.
While taking an adult patient's pulse, a nurse find the rate to be 140 beat/min. What should the nurse do next?
Report the rate to the primary care provider.
A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:
The highest pressure present on arterial walls while the ventricles contract.
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plane to take?
Use a gait belt to stand and pivot the client.
A nurse at an extended care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients use of a cane?
When the client moves, he should move the cane forward first.
