Vital Signs
Upon examination the patient presents with a respiratory rate of 28 breaths per minute, what should the nurse document?
1. tachypnea
2. bradypnea
3. crackles
4. diplopia
1. tachypnea
Fast respiratory rate (>20 breaths per minute)
The nurse walks in the room and sees the patient bleeding from the nose. What term would she use to document the event?
1. Obtundation
2. Decerebrate
3. Epistaxis
4. Nose Bleed
3. Epistaxis
Epistaxis is the medical term for nose bleed
What is capillary refill checking for? What is a normal cap refill?
Capillary refill is assessing for blood flow to the tissue.
Normal capillary refill time is 1-2 seconds
A patient states, "I was told one lung has more lobes than the other". How would you respond?
It is true, the right lung has 3 lobes, and the left lung has 2, which allows room for the heart to expand with each beat.
An infant is brought to the ER, how do you assess their pain?
FLACC scale
Face, Legs, Activity, Crying, Consolable
A patient came in with a heart rate of 97 bpm, what is the nurses next step?
1. Call the doctor and report the finding
2. Give a beta blocker to reduce the heart rate
3. Document it as a normal finding
4. Call a code
3. Document it as a normal finding
60-100 bpm is the normal range
The nurse is assessing the pupils of a patient with a pen light. Which finding would be considered normal?
1.Both eyes cross when exposed to the light.
2.The patient’s pupils are fixed and dilated in response to light.
3.Both pupils dilate in response to light.
4.Both pupils constrict in response to light.
4. Both pupils constrict in response to light
This is an expected finding, indicating no neuro/pupillary problems
What does the acronym ABCDEF stand for in skin exams?
Asymmetry, Border, Color, Diameter greater than 6mm, elevation/evolution, and is it funny looking?
A patient presents with barrel chest, what assessment finding supports this?
1. Asymmetrical chest wall expansion
2. Broken rib on left side
3. AP diameter of 2:1
4. Bronchiovesicular lung sounds present
3. AP diameter of 2:1
A normal AP diameter should be 1:2, AP should never be greater than the transverse diameter (TD). Barrel chest can be seen in patients with COPD, asthma, etc. anytime there was prolonged difficulty breathing utilizing accessory muscles
Upon tympanic membrane inspection, where would you expect to see the cone of light in the right ear and the left ear?
Light reflex (cone of light) present at 5 o’clock in the right eardrum and 7 o’clock in the left eardrum
remember 7 eLeven
Which Korotkoff phase determines the diastolic blood pressure reading?
1. I
2. IV
3. V
4. VI
3. V
Korotkoff V is the diastolic BP, when the sound disappears
A patient's test came back positive for an STI (sexually transmitted infection), what would support this diagnosis?
1. Swollen Axillary Lymph nodes
2. Chest pain
3. Positive CVA (costovertebral angle) test
4. Swollen Inguinal Lymph nodes
4. Swollen Inguinal Lymph nodes
The lymph system is the drainage system of the body. Inflammation in a lymph node suggests infection in that area. Swollen inguinal lymph nodes would concur with the diagnosis of an STI.
The nurse gets report on a patient that has was transferred to the unit. The nurse was told the skin was clear, upon examination the nurse finds a sacral pressure ulcer with partial thickness skin loss with exposed dermis. What would she document (grade it)?
Stage 2 pressure ulcer, the second layer of skin is exposed (dermis).
A patient states, "Every night I wake up because I feel so short of breath", what would be the medical term for this occurence?
1. Paroxysmal Nocturnal Dyspnea
2. Enuresis
3. Somnambulism
4. Orthopnea
1. Paroxysmal Nocturnal Dyspnea
This is the condition in which you wake up feeling short of breath throughout the night
When using an otoscope to inspect the internal canal of a 2 year old, how should you pull the pinna?
Pull the pinna down in ANYONE under 3 years
pull pinna up and back in anyone 3+
A 27-year-old male comes in for his annual exam. During the exam he states that he competes in body building competitions and eats upwards of 3,000 k/cal per day. He's 6'1 and weighs 230 lbs. His BMI is 30.1, what should the nurse say?
1. This BMI suggests you are obese and need to loose weight
2. You are within normal BMI range, and healthy
3. Your BMI is considered obese, but it doesn't take into account muscle mass
4. Your BMI is low, you should increase your calorie amount
3. 3. Your BMI is considered obese, but it doesn't take into account muscle mass
BMI readings can be inaccurate for weight lifters since it cannot differentiate weight from muscles or weight from fat
While assessing pupillary reflex, your professor asks you which cranial nerves you are assessing. What would you say?
1. I and II
2. II and III
3. I and IV
4. IV and V
2. II and III
II is Optic, primary function is vision
III is Oculomotor, parasympathetic function is pupil constriction and lens shape
A patient is crying and says, “Please get me something to relieve this pain.” What should the nurse do next?
1.Verify that the patient has an order for pain medications and administer order as directed.
2.Assess the level of pain and ask the patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.
3.Assess the level of pain and give medications according to pain level, and then reassess pain.
4.Reposition the patient, then reassess the pain after intervention.
2.Assess the level of pain and ask the patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.
This answer most properly represents OLDCART and adequate nursing role/documentation
A patient presents with bilateral crackles (rales), the patient is scared and asks the nurse what it means. What is most likely happening?
Crackles (rales) indicates that there is fluid in the lungs (surrounding the alveoli), that patient most likely has pnemonia
A patient presents in Heart Failure, she has gained 20 lbs in two days. (1) What stage of edema would we expect, (2) where could you check for it and (3)why?
(1) stage 4 pitting edema, leaves an indent for longer than 2 minutes
(2) you can check the lungs (crackles), or limbs (ankles, shins, arms, etc.)
(3) If the patient gained 20lbs in 2 days, she has an extreme amount of fluid onboard. Assessing the status and location of her fluid is critical to tell the doctor and document as her start
The nurse is assessing a patient with a heart rate of 55. Which of the following patients would be most likely to have a pulse rate of 55?
1.A 70-year-old telephone salesman who is dehydrated
2.A 20-year-old runner who had surgery 4 days ago for a fractured leg
3.A 67-year-old who presented with an exacerbation of his COPD
4.An infant who has a temperature of 100.1°F
2.A 20-year-old runner who had surgery 4 days ago for a fractured leg
Athletes tend to have lower resting heart rates due to stronger cardiac muscle
A nurse needs to perform the Rinne's test, the patient asks what it is, how would you describe it to them?
I will place tuning fork at your mastoid (bone behind the ear) then move to external auditory canal (ear canal)
Air conduction sound is normally heard twice as long as bone conduction sound (AC > BC). Once you remove the tuning fork from the mastoid and place it in front of the auditory canal, the sound should still be heard. If the patient no longer hears the noise once removed from the mastoid, they are positive for conductive hearing loss (BC > AC)
1. Menstrual Cramps
2. Fractured Tibia
3. Jaw pain from a heart attack
a. Referred Pain
b. Visceral Pain
c. Deep Somatic Pain
1 B (cramps come from the uterus, an internal organ)
2 C (Deep somatic pain comes from blood vessels, joints, tendons, muscles, and bones)
3 A (referred pain causes pain that is not in the originating location, when someone has a heart attack pain can radiate to the jaw and may be felt more intensely in the jaw)
A patient came to the hospital after recently traveling back from Paris. She was complaining of calf pain then began gasping for air and struggling to breathe. What is likely happening to your patient?
She is most likely experiencing a pulmonary embolus (PE) related to a VTE (venous thromboembolism, formerly known as a DVT) from her recent travels (prolonged sitting position from flying creates clotting in the legs, a clot broke off and traveled to the lungs)
Describe the difference between Nociceptive and Neuropathic pain, give an example for each
Nociceptive pain
Develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
Triggered by outside events from the nervous system as a result of actual or potential damage
EX. getting hit by a car
Neuropathic Pain
implies an abnormal processing of pain message that is difficult to assess and treat.
Often perceived long after site of injury heals
cannot be identified by x-ray, computerized axial tomography (CAT) scan, or magnetic resonance imaging (MRI)
EX. Diabetes mellitus, herpes zoster (shingles), HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy