A
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
A. Heart Murmurs
B Jugular venous hums
C Bowel Sounds
D Carotid Bruits
C Bowel Sounds
A patient fell from a ladder and now has a swollen left ankle. It would demonstrate good nursing judgement if the nurse assessed pulses at which site?
A.Right Carotid
B. Left Dorsalis Pedis
C.Left Popliteal
D.Right Posterior Tibial
B. Left Dorsalis Pedis
A nurse notes that when she took an oral temp on her patient, it was much higher than the baseline in the patient's chart. What factor could have influenced that discrepancy?
A. The baseline temperature was obtained shortly after the client returned from Physical Therapy and the subsequent reading was taking while patient was reading a book.
B. The baseline reading was taken axillary and the subsequent reading was taken orally.
C. The patient ingested ice tea within 10min of the subsequent reading
D. The patient smoked shortly before the first baseline reading was obtained
B. The baseline reading was taken axillary and the subsequent reading was taken orally.
A nurse is obtaining vital signs on her elderly patient. The nurse obtains a blood pressure of 135/84. What is her next best action?
A.Compare to baseline and document the findings
B.Call the physician
C.Education the client regarding hypertension
D.Check the MAR to see when the patient last received BP medication
A.Compare to baseline and document the findings
A hospitalized patient complains of abdominal pain that ranks 9 on a scale of 1 to 10. After obtaining the pain rating, what is the nurse’s next best step?
A.Assess the client’s vital signs to see if they match his report of pain
B.Ask the client to describe the pain
C.Check to see when the last time the patient received his pain medication was
D.Administer ordered pain medication
B.Ask the client to describe the pain
A nurse obtained vital signs on a previously stable patient and got a temperature of 100.7 orally. What action is appropriate at this time?
A.Document the findings
B.Call the doctor to inform him of the abnormal vital sign
C.Check the patient for other signs and symptoms of infection
D.Obtain the temperature using a different route
D.Obtain the temperature using a different route
A patient has lost a lot of blood from surgery. Which vital sign change would the nurse not expect to see as a result of the massive blood loss?
A. HR of 118
B.BP of 80/45
C.RR of 8
D.Temp of 100.8
C.RR of 8
A nurse is observing a CNA obtain vital signs. Which action, if observed, would require the nurse to intervene?
A.The CNA notices the client’s fingers are very cold so they place pulse ox probe on their earlobe instead to obtain 02 sats
B.The CNA waits 30min to obtain temperature after a patient returns to the floor from smoking
C.The CNA prioritizes obtaining vital signs on a patient that recently returned from surgery
D.The CNA notices a patient has a right forearm IV and has had a left mastectomy, so chooses to obtain blood pressure on the right arm
D.The CNA notices a patient has a right forearm IV and has had a left mastectomy, so chooses to obtain blood pressure on the right arm
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take?
A.Give him some non-skid slippers and tell him where the bathroom is located.
B.Ask the nursing assistant to assist him to the bathroom.
C.Obtain orthostatic blood pressure measurements.
D.Tell him it is not a good idea and provide a urinal.
C.Obtain orthostatic blood pressure measurements.
Upon doing a shift assessment at 0800 a patient asks for their morphine and states their pain is a 9/10 despite laughing with visitors and all vitals being within normal range. The nurse sees the Morphine is ordered q2h PRN for pain and the patient last received the med exactly 2 hours ago. What is the nurse's best action at this time.
A. Give the patient a different pain medication that is ordered such as Ibuprofen instead
B. Call the doctor and discuss concerns about narcotic abuse. Request a different medication be ordered.
C. Administer the Morphine as requested
D. Look at patient's chart for how often he has been receiving the narcotic.
C. Administer the Morphine as requested
A nurse suspects the CNA is falsifying her vital signs. Many of the patients on the floor have similar vitals, which do not match their individual baselines. What is the nurse’s best initial approach to this situation?
A.Report the CNA to the charge nurse
B.Recheck the patient’s vital signs and document those findings
C.Speak to the CNA about the suspicions in private
D.Delegate the next set of vital signs to a different CNA and compare the data to the suspicious set
B.Recheck the patient’s vital signs and document those findings
Upon obtaining a radial pulse on a patient, the nurse notes the pulse is increased and very weak. What could this indicate?
A. The patent has poor circulation
B. The patient has low fluid status
C. The patient needs to hang the extremity in the dependent position for a while
D. The nurse is probably using poor technique to obtain the pulse
B. The patient has low fluid status
A nurse obtained a temperature reading of 97.3 for her hospitalized client who normally runs close to the normal 98.6. Which of the following situations may have led to that reading?
A. The nurse took the reading after the patient returned from smoking
B. The nurse obtained that reading rectally and normally the reading is obtained axillary
C. The nurse obtained the reading at her 0400 routine vital signs
D. The patient has an active infection they are being treated for.
C. The nurse obtained the reading at her 0400 routine vital signs
A nurse is assessing patients most at risk for hypertension. The nurse would be correct in stating that the patient who is most at risk for hypertension is who?
A. The 25yo Asian athlete who smokes 1 pack per day
B. The 76 yo african american ice cream shop owner
C. The 12yo overweight female softball player
D. The 60 yo female who has had issues with orthostatic hypotension in the past
B. The 76 yo african american ice cream shop owner
A nurse is assessing pain on a developmentally delayed adult client. After trying the normal 0-10 pain scale, and Wong-Baker it's clear the client does not understand. What is the nurse's next best action?
A. Ask the family if they think the patient is in pain
B. Skip the pain scale and just ask the patient to point to where it hurts
C. Use the FLACC scale
D. Look for vital sign changes such as BP, HR, and RR to determine if the client is experiencing any pain.
C. Use the FLACC scale
A nurse is educating her patient on factors that can affect body temperature. Which of the following factors would need to be included in the teaching (select all that apply).
A. Stress
B. Age
C. Hormones
D. Environment
E. Position
A. Stress
B. Age
C. Hormones
D. Environment
A nurse is educating her elderly patient on reasons why his systolic BP is increased from when he was younger. The nurse notes her patient has understood the teaching when he states what?
A. My vessels have thickened and become more stenosed over time
B. My vessels are more compliant and flexible then when I was younger
C My vessels have dilated more as I have aged
D. My heart is pumping more fluid out then when I was younger
A. My vessels have thickened and become more stenosed over time
When obtaining vitals signs on her group of patients, which patient is a priority to follow up on?
A. The patient who's RR increased from 18 to 28 shortly after exercising
B. The patient who's BP dropped from 130/90 to 115/80 after going from sitting to standing
C. The patient who's RR dropped from 16 to 8 following a narcotic administration
D. The patient's who's HR went from 90 to 120 after ambulating in the hall.
C. The patient who's RR dropped from 16 to 8 following a narcotic administration
A preceptor is educating a new nurse regarding orthostatic hypotension. She would be correct in stating that which of the following patients below fits the criteria for orthostatic hypotension?
A. The patient who's BP went from 90/60 to 100/65 when going from laying to sitting
B. The patient who's BP went from 140/80 to 110/60 when going from standing to laying
C. The patient who's BP went from 130/80 to 125/65 when going from sitting to standing
D. The patient who's BP went from 120/80 to 110/80 when going from laying to sitting.
C. The patient who's BP went from 130/80 to 125/65 when going from sitting to standing
A nurse is admitting a client with a fractured femur and obtains BP of 140/94. The client denies any history of hypertension. What action should the nurse take first?
A. Request a prescription for a anti-hypertensive medication
B. Ask the client if they are experiencing any pain.
C. Request a prescription for an anti-anxiety medication
D. Return in 30min and recheck the BP on a different extremity
B. Ask the client if they are experiencing any pain.
A nurse is caring for an 80 yo client in the ER who has a body temperature of 101 orally, HR 114, RR 22. Patient is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply)
A. Obtain blood culture specimens per MD orders to check for infectious processes
B. Restrict the client's fluid intake
C. Encourage the client to limit activity
D. Allow the client to shiver to dispel excess heat
E. Assist the client with oral hygiene frequently
A. Obtain blood culture specimens to check for infectious processes
C. Encourage the client to limit activity
E. Assist the client with oral hygiene frequently
A nurse is instructing her CNA about caring for a client who is at risk for bleeding from a low platelet count as a result of chemotherapy. Which instructions is the priority for measuring vital signs in this patient?
A. Do not measure the clients temperature rectally
B. Be sure you listen to heart rate for a full minute
C. Be sure when you count respirations you do not tell the client that is what you are doing
D. Let the client rest for 15-30min before you measure her BP
A. Do not measure the clients temperature rectally
A nurse is instructing a group of nursing students on how to measure respiratory rate. Which of the following guidelines should the nurse include (select all that apply).
A. Place the client in a Semi-Fowler's or Fowler's position
B. Have the client lay flat before counting
C. Observe one full respiratory cycle before starting to count the rate
D. Count the rate for 30sec and multiply by 2 instead of counting for 15 sec and multiplying by 4 if it's irregular
E. Document and report any adventitious breath sounds auscultated
A. Place the client in a Semi-Fowler's or Fowler's position
C. Observe one full respiratory cycle before starting to count the rate
E. Document and report any adventitious breath sounds auscultated
A nurse is taking the blood pressure of her patient and notes that its uncharacteristically low for their baseline. What factor is most likely contributing to the low reading?
A. The nurse chose a cuff that was too small for the patient
B. The nurse obtained the blood pressure late in the day
C. The patient is elderly
D. The equipment may not be reliable and the nurse should do a manual BP to confirm
D. The equipment may not be reliable and the nurse should do a manual BP to confirm
A nurse needs to obtain a blood pressure on a client. This is the client's first BP assessment in this facility. How does the nurse know how high to inflate the cuff?
A. Ask the client what they normally run and inflate 10mmHg above their stated norm
B. Automatically inflate to 200mmHg and then note their normal range for future assessments
C. Use the palpatory method to determine maximum inflation
D. Pull client records to see what they ran at their most recent doctor's appointment.
C. Use the palpatory method to determine maximum inflation