NCLLEX Style
Vital Signs
Vital Signs
A nurse is caring for a 72-year-old patient who was admitted with pneumonia. The patient's vital signs upon admission were: temperature 101.2°F (38.4°C), heart rate 88 beats per minute, respiratory rate 22 breaths per minute, and blood pressure 130/76 mmHg. After administering the prescribed antipyretic medication, which of the following findings would indicate the need for reassessment of the patient's vital signs?
A) The patient's temperature decreases to 99.5°F (37.5°C).
B) The patient's heart rate increases to 110 beats per minute.
C) The patient's respiratory rate decreases to 18 breaths per minute.
D) The patient's blood pressure remains stable at 128/74 mmHg.
Correct Answer:
B) The patient's heart rate increases to 110 beats per minute.
Rationale:
An increase in the patient's heart rate to 110 beats per minute is a significant change that warrants reassessment of vital signs. This could indicate a response to the medication, a change in the patient's condition, or the development of a new issue such as dehydration or worsening infection. Monitoring and reassessing vital signs in response to such changes are crucial for ensuring patient safety and appropriate intervention.
Located on the neck, besides the trachea
Carotid Pulse
A nurse is educating a group of nursing assistants about fall prevention strategies for elderly patients in a long-term care facility. Which statement by one of the nursing assistants indicates a misconception about fall prevention and safety?
A) "We should ensure that the call light is within reach of the patient at all times."
B) "It's important to keep the bed in the lowest position to prevent falls."
C) "Using physical restraints can help prevent falls in patients who are at high risk."
D) "We should remove any clutter or obstacles from the patient's room."
Correct Answer:
C) "Using physical restraints can help prevent falls in patients who are at high risk."
Rationale:
A nurse is assessing a patient and notes a blood pressure reading of 90/70 mmHg, resulting in a pulse pressure of 20 mmHg. Which of the following clinical findings or conditions could be associated with this low pulse pressure? Select three that apply.
A) Aortic stenosis
B) Hyperthyroidism
C) Cardiac tamponade
D) Severe dehydration
E) Anemia
F) Heart failure
Correct Answers:
A) Aortic stenosis
C) Cardiac tamponade
F) Heart failure
Rationale:
Aortic Stenosis: This condition involves the narrowing of the aortic valve, which can reduce the systolic pressure and lead to a low pulse pressure due to decreased blood ejection from the heart.
Cardiac Tamponade: In this condition, fluid accumulation in the pericardial sac restricts the heart's ability to fill and pump effectively, resulting in a low pulse pressure.
Heart Failure: Reduced cardiac output in heart failure can lead to a narrow pulse pressure as the heart struggles to maintain effective circulation.
A registered nurse (RN) is delegating tasks to a Unlicensed Assistive Personnel (UAP) on a busy medical-surgical unit. Which task is appropriate for the RN to delegate to the UAP?
A) Administering oral medications to a stable patient.
B) Assessing a patient's pain level after surgery.
C) Assisting a patient with ambulation to the bathroom.
D) Developing a care plan for a newly admitted patient.
Correct Answer:
C) Assisting a patient with ambulation to the bathroom.
Rationale:
A nurse is assessing the vital signs of a 45-year-old patient who has just returned to the surgical unit after an appendectomy. Which of the following vital sign findings should be reported to the healthcare provider immediately?
A) Temperature of 99.0°F (37.2°C)
B) Heart rate of 98 beats per minute
C) Respiratory rate of 8 breaths per minute
D) Blood pressure of 118/76 mmHg
Correct Answer: C) Respiratory rate of 8 breaths per minute
Rationale:
A respiratory rate of 8 breaths per minute is significantly below the normal range (typically 12-20 breaths per minute for adults) and may indicate respiratory depression, which can be a serious complication, especially postoperatively. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. The other vital sign values are within normal limits or expected ranges for a postoperative patient.
Located on the side of the head
Temporal Pulse
A nurse is providing education to a group of elderly patients about fall prevention at home. Which statement by one of the patients indicates a misconception about wearing footwear indoors?
A) "I should wear shoes with non-slip soles when walking around the house."
B) "It's okay to wear any type of footwear indoors as long as I'm comfortable."
C) "I should avoid walking barefoot to reduce the risk of slipping."
D) "Wearing well-fitted slippers can help prevent falls."
Correct Answer:
B) "It's okay to wear any type of footwear indoors as long as I'm comfortable."
Rationale:
A nurse is assessing a patient and notes a blood pressure reading of 160/80 mmHg, resulting in a pulse pressure of 80 mmHg. Which of the following clinical findings or conditions could be associated with this high pulse pressure? Select three that apply.
A) Aortic regurgitation
B) Hypothyroidism
C) Arteriosclerosis
D) Chronic hypertension
E) Dehydration
F) Mitral stenosis
-Correct Answers:
A) Aortic regurgitation
C) Arteriosclerosis
D) Chronic hypertension
[Rationale] A high pulse pressure generally indicates:
Arteriosclerosis: Stiffening or hardening of the arteries can lead to increased systolic pressure, resulting in a widened pulse pressure. This is common in older adults as the elasticity of the arteries decreases with age.
Hyperthyroidism: This condition can increase cardiac output and lead to a higher systolic pressure, thus widening the pulse pressure.
Aortic Regurgitation: In this condition, the aortic valve does not close properly, allowing blood to flow back into the heart, which can increase systolic pressure and widen pulse pressure.
Chronic Hypertension: Long-standing high blood pressure can lead to changes in the arterial system that result in a widened pulse pressure.
Anemia: Severe anemia can increase cardiac output to compensate for reduced oxygen-carrying capacity, potentially leading to a widened pulse pressure.
Fever or Sepsis: These conditions can increase cardiac output and lead to a widened pulse pressure due to systemic vasodilation and increased metabolic demand.
A registered nurse (RN) is working with a Unlicensed Assistive Personnel (UAP) on a medical-surgical unit. Which routine task can the RN delegate to the UAP?
A) Performing a head-to-toe assessment on a newly admitted patient.
B) Monitoring and recording vital signs for stable patients.
C) Evaluating a patient's response to pain medication.
D) Educating a patient about postoperative care instructions.
Correct Answer:
B) Monitoring and recording vital signs for stable patients.
Rationale:
How is pulse pressure calculated and the normal range?
Pulse Pressure = (Systolic BP - Diastolic BP)
Normal Range: 30 to 40 mmHg
Located on the inner aspect of the arm, near the elbow crease.
Brachial Pulse
A nurse is conducting a fall prevention workshop for caregivers of elderly patients. Which statement by one of the caregivers indicates a misconception about fall risk?
A) "Implementing a personalized fall prevention plan can help reduce the risk of future falls."
B) "Once someone falls, they will always fall, so there's not much we can do to prevent it."
C) "Regular exercise can improve balance and strength, reducing the likelihood of falls."
D) "Reviewing medications with a healthcare provider can help identify those that may increase fall risk."
Correct Answer:
B) "Once someone falls, they will always fall, so there's not much we can do to prevent it."
A nurse is assessing the posterior tibialis pulse of a patient. Where should the nurse palpate to locate this pulse?
A) Behind the knee in the popliteal fossa
B) On the top of the foot between the first and second toes
C) Behind the medial malleolus of the ankle
D) On the lateral aspect of the ankle, just below the fibula
Correct Answer:
C) Behind the medial malleolus of the ankle
Unlicensed Assistive Personnel (UAP) on the unit. Which task related to medication administration can the RN delegate to the UAP?
A) Administering oral medications to a stable patient.
B) Applying a prescribed medicated cream to a patient's skin.
C) Observing and reporting any side effects after a patient receives medication.
D) Transporting medications from the pharmacy to the unit.
Correct Answer:
D) Transporting medications from the pharmacy to the unit.
Rationale:
A nurse is reviewing the vital signs of a 60-year-old patient with a history of hypertension. The patient's blood pressure is recorded as 150/90 mmHg. What is the patient's pulse pressure, and how should the nurse interpret this finding?
A) Pulse pressure is 40 mmHg; this is a normal finding.
B) Pulse pressure is 60 mmHg; this indicates widened pulse pressure.
C) Pulse pressure is 30 mmHg; this indicates narrowed pulse pressure.
D) Pulse pressure is 50 mmHg; this is a normal finding.
Correct Answer: B) Pulse pressure is 60 mmHg; this is a normal finding.
Rationale:
Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, 150 mmHg (systolic) - 90 mmHg (diastolic) = 60 mmHg. However, the correct calculation should be 150 - 90 = 60 mmHg, which indicates a widened pulse pressure. The normal pulse pressure range is typically between 30 and 40 mmHg. A pulse pressure of 60 mmHg is considered widened and may be associated with conditions such as atherosclerosis or increased stroke volume. Therefore, the correct interpretation should be that the pulse pressure is widened, not normal. I apologize for the initial error in the answer choice.
Located on the back of the knee
Popliteal Pulse
A nurse is teaching a group of elderly patients about the use of assistive devices for mobility. Which statement by one of the patients indicates a misconception about using a walker or cane?
A) "Using a walker or cane can help improve my stability and balance."
B) "I should ensure my walker or cane is properly adjusted to my height for safe use."
C) "Using a walker or cane will prevent all falls, so I don't need to worry about other precautions."
D) "I should continue to be cautious and aware of my surroundings even when using a walker or cane."
Rationale:
A nurse is caring for a patient who is confused and at risk of pulling out their IV line. The healthcare team is considering the use of restraints. Which statement by the nurse reflects an understanding of the ethical and legal concerns associated with the use of restraints?
A) "Restraints can be used whenever a patient is confused to ensure their safety."
B) "I must obtain a physician's order and ensure that all other alternatives have been exhausted before applying restraints."
C) "Once restraints are applied, I do not need to monitor the patient as frequently."
D) "Using restraints is a standard practice for all patients who are at risk of falling."
Correct Answer:
B) "I must obtain a physician's order and ensure that all other alternatives have been exhausted before applying restraints."
Rationale:
A registered nurse (RN) is working with a Unlicensed Assistive Personnel (UAP) on a busy hospital unit. Which communication task is appropriate for the RN to delegate to the UAP?
A) Explaining a new diagnosis to a patient and their family.
B) Reporting a change in a patient's condition to the healthcare provider.
C) Documenting a patient's intake and output in the medical record.
D) Providing discharge instructions to a patient.
Correct Answer:
C) Documenting a patient's intake and output in the medical record.
Rationale:
A nurse is providing education to a 55-year-old patient who has been diagnosed with prehypertension, with recent blood pressure readings averaging 128/84 mmHg. Which of the following lifestyle modifications should the nurse emphasize to help manage the patient's blood pressure? Select two that apply.
A) Reduce sodium intake to less than 1,500 mg per day.
B) Engage in at least 30 minutes of moderate-intensity exercise most days of the week.
C) Increase caffeine consumption to improve alertness.
D) Follow a high-protein diet to promote muscle growth.
E) Limit alcohol consumption to moderate levels.
Correct Answers: A, B
Rationale:
Reducing sodium intake to less than 1,500 mg per day is recommended for individuals with prehypertension to help lower blood pressure. Engaging in regular physical activity, such as 30 minutes of moderate-intensity exercise on most days, is also beneficial for managing blood pressure. These lifestyle modifications can help prevent the progression to hypertension. Increasing caffeine consumption and following a high-protein diet are not specifically recommended for blood pressure management. Limiting alcohol consumption is important, but the question asks for the two most emphasized lifestyle changes.
Sometimes used infants or when other pulse points are not accessible.
Temporal Pulse
Question:
A nurse is providing education on fall prevention to a community group. Which statement by a participant indicates a misconception about who is at risk for falls?
A) "Falls can happen to anyone, regardless of their health status."
B) "Only frail or sick people fall, so I don't need to worry about it."
C) "Environmental hazards, like loose rugs, can increase the risk of falls for everyone."
D) "Staying physically active can help reduce the risk of falls."
Correct Answer:
B) "Only frail or sick people fall, so I don't need to worry about it."
Rationale:
Correct Options:
A) "Falls can happen to anyone, regardless of their health status." This is a correct statement. Falls are a risk for people of all ages and health conditions.
C) "Environmental hazards, like loose rugs, can increase the risk of falls for everyone." This is a correct statement. Environmental factors can contribute to falls regardless of a person's health.
D) "Staying physically active can help reduce the risk of falls." This is a correct statement. Physical activity can improve strength and balance, reducing fall risk.
A nurse is preparing to assess the apical pulse of a patient. Which of the following steps should the nurse take to accurately locate the apical pulse? Select all that apply.
A) Position the patient in a supine or slightly left lateral position.
B) Locate the second intercostal space at the right sternal border.
C) Identify the fifth intercostal space at the midclavicular line on the left side.
D) Use the diaphragm of the stethoscope to auscultate the apical pulse.
E) Palpate the radial pulse simultaneously to confirm accuracy.
F) Count the pulse for 15 seconds and multiply by four to determine the rate.
Correct Answers:
A) Position the patient in a supine or slightly left lateral position.
C) Identify the fifth intercostal space at the midclavicular line on the left side.
D) Use the diaphragm of the stethoscope to auscultate the apical pulse.
Rationale:
A) Position the patient in a supine or slightly left lateral position: This position helps bring the heart closer to the chest wall, making it easier to locate and auscultate the apical pulse.
C) Identify the fifth intercostal space at the midclavicular line on the left side: This is the correct anatomical location for assessing the apical pulse.
D) Use the diaphragm of the stethoscope to auscultate the apical pulse: The diaphragm is used to listen to high-pitched sounds, such as the heart sounds at the apical pulse.
A registered nurse (RN) is working with a Unlicensed Assistive Personnel (UAP) on a medical-surgical unit. Which task related to observation and reporting can the RN appropriately delegate to the UAP?
A) Assessing a patient's pain level and determining the need for pain medication.
B) Monitoring a patient's vital signs and reporting any values outside the normal range to the RN.
C) Evaluating a patient's response to a new medication.
D) Interpreting laboratory results and notifying the healthcare provider of any abnormalities.
Correct Answer:
B) Monitoring a patient's vital signs and reporting any values outside the normal range to the RN.
Rationale:
A nurse is caring for a 68-year-old patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy via nasal cannula at 2 liters per minute. The patient's current oxygen saturation is 88%. Which of the following actions should the nurse take first?
A) Increase the oxygen flow rate to 4 liters per minute.
B) Encourage the patient to perform pursed-lip breathing.
C) Notify the healthcare provider immediately.
D) Position the patient in a high Fowler's position.
Correct Answer: B) Encourage the patient to perform pursed-lip breathing.
Rationale:
In patients with COPD, an oxygen saturation level of 88% can be acceptable due to their chronic condition and adaptation to lower oxygen levels. Pursed-lip breathing is a technique that can help improve ventilation and oxygenation by promoting more effective exhalation and reducing air trapping. This non-invasive intervention should be attempted first. Increasing the oxygen flow rate without a provider's order can lead to complications such as CO2 retention in COPD patients. Notifying the healthcare provider and repositioning the patient may be appropriate actions if the initial intervention does not improve the patient's condition.
Assessed using a stethoscope, especially in cases of irregular heart rhythm or when peripheral pulses are difficult to palpate.
Apical Pulse
A nurse is conducting a home safety assessment for an elderly patient. Which statement by the patient indicates a misconception about the need for home modifications?
A) "Home modifications can help prevent falls before they happen."
B) "I haven't fallen yet, so I don't need to make any changes to my home."
C) "Installing grab bars in the bathroom can improve my safety."
D) "Removing clutter from walkways can reduce my risk of tripping."
Correct Answer:
B) "I haven't fallen yet, so I don't need to make any changes to my home."
Rationale:
A nurse is caring for an elderly patient who is at risk of falling. The nurse considers raising all four side rails on the patient's bed. Which statement by the nurse reflects an appropriate understanding of the use of side rails as physical restraints?
A) "Raising all four side rails is a standard practice to prevent falls in all patients."
B) "Raising all four side rails can be considered a form of restraint and should be used cautiously."
C) "Using all four side rails is not considered a restraint and does not require a physician's order."
D) "It is safe to leave all four side rails up as long as the patient is in a hospital setting."
Correct Answer:
B) "Raising all four side rails can be considered a form of restraint and should be used cautiously."
Rationale:
A registered nurse (RN) is working with a Unlicensed Assistive Personnel (UAP) on a postoperative unit. Which task related to patient care and comfort can the RN appropriately delegate to the UAP?
A) Performing a sterile dressing change on a surgical wound.
B) Assisting a patient with bathing and personal hygiene.
C) Assessing a patient's incision site for signs of infection.
D) Educating a patient about postoperative exercises.
Correct Answer:
B) Assisting a patient with bathing and personal hygiene.
Rationale: