Practice Question ch 12

Question 1

A patient is undergoing antibiotic therapy for pneumonia . His rectal temperature reading is 101.6 F. What is the expected oral temperature reading?

1. 101.6F (38.7C)
2. 100.6F (38.1C)
3. 99.6F (37.5C)
4. 97.6F (36.4 C)

Answer 1

2

Question 2

A patient has a postpartum temperature that is elevated in the evening but returns to a normal reading in the morning. This has occurred for several days. What is this type of fever classification?

1. Constant 2. Intermittent 3. Remittent 4. Crisis

Answer 2

2

Question 3

A patient has a 10-year history of coronary artery disease. The patient is recovering from a myocardial infarction . What is the most accurate way for the nurse to assess the pulse rate?

1. Carotid pulse 2. Radial pulse 3. Apical pulse 4. Brachial pulse

Answer 3

3

Question 4

An adult patient is admitted to the emergency department with an exacerbation of asthma. Respirations are 40 breaths per minute . After treatment, the rate returns to normal limits. What respiratory range is considered to be normal?

1. 30 to 60
2. 12 to 20
3. 16 to 22
4. 24 to 30

Answer 4

2

Question 5

During a routine physical examination , a patient’s blood pressure is noted at 180/90 mm Hg. The patient states, Oh no, I didn’t know I had high blood pressure,” The nurse is aware that the patient’s blood pressure must measure above what level at two separate office visits for the patient to be diagnosed with hypertension ?

1. 160/100 mm Hg
2. 140/90 mm Hg
3. 130/70 mm Hg
4. 120/80 mm Hg

Answer 5

2

Question 6

A 65-year-old man has a history of emphysema resulting from 30 years of cigarette smoking. He frequently reports dyspnea. What is dyspnea?

1. Pallor
2. Absence of retractions
3. Cyanosis
4. Difficulty breathing

Answer 6

4

Question 7

A patient reports palpitations that result from anxiety over an impending surgery. The pulse rate is found to be 110 beats per minute . How will the nurse describe this heart rate ?

1. Bradycardia
   2.Tachycardia
2. Tachypnea
3. Hypertension

Answer 7

2

Question 8

The nurse obtains a supine blood pressure reading of 130/64 mm Hg. One hour later, the nurse obtains a supine blood pressure reading of 134/62 mm Hg and a sitting blood pressure reading of 95/62 mm Hg. What should be the immediate action of the nurse?

1. Assist the patient to return to a supine position
2. Obtain a blood pressure reading in the other arm.
3. Report the findings to the nurse in charge.
4. Question the patient about any symptoms .

Answer 8

4

Question 9

The nurse is assessing a patient’s blood pressure for the first time as part of the patient’s postoperative assessment. After reaching the point at which the radial pulse is obliterated, what is the next action of the nurse?

1. Deflate the slowly and wait 15 to 20 seconds before reinflating
2. Deflate the cuff rapidly and wait 15 to 30 seconds before reinflating
3. Deflate the cuff slowly and wait 1 minute before reinflating.
4. Deflate the rapidly and wait 1 minute before reinflating

Answer 9

4

Question 10

The nurse has been assigned several patients. Which patient is most likely to have a higher-than-normal temperature? (Select all that apply)

1. A depressed, apathetic patient
2. A patient assessed with hemorrhage
   3.A patient who is recovering from surgery
3. A patient who just finished eating
4. A patient who has a temperature of 101.4 F

Answer 10

4,5

Question 11

A patient is admitted after a motorcycle accident. The nurse is assessing the pulse pressure. The blood pressure reading is 140/102 mm Hg. What is the correct pulse pressure?

Answer 11

38

Question 12

The nurse is preparing to assess a 2- day-old infant’s pulse rate. Which site should be used?

1. Scalp artery 2. Femoral artery 3. Apical site 4. Radial site

Answer 12

3

Question 13

. The nurse is assessing a postoperative patient’s apical and radial pulses. Which statement is correct concerning this assessment of the patient’s apical and radial pulse measurements ?

1. The apical pulse and radial pulse should be taken for 1 full minute each
2. The apical and radial pulse rates are lower when the temperature is elevated .
3. The apical and radial pulses are taken at the same time for 30 seconds
4. The apical and radial pulses are taken at the same time for 60 seconds.

Answer 13

1

Question 14

The health care provider has ordered an orthostatic blood pressure measurement . Place the following statements in correct order concerning the orthostatic method of assessing blood pressure.
1. The measurement is taken when the patient is standing.
2. The measurement is taken with the patient lying down.
3. The nurse assesses the blood pressure in the sitting position .
4. The nurse documents the blood pressure readings.

Answer 14

2,3,1,4

Question 15

The patient’s oral temperature is 37. What is the appropriated reporting of this temperature?

1. Febrile 2. Afebrile 3. Hypotensive 4. Hypertensive

Answer 15

2

Question 16

Which is an important factor in the measurement of vital signs ? ( Select all that apply )

1. Ranges of normal for vital signs are very narrow and apply to all patients .
2. The most significant aspect of measuring vital signs is their documentation .
3. Environmental factors have an insignificant effect on the patient’s vital signs .
4. All measuring equipment is chosen on the basis of the patient’s conditions and characteristics
5. Smoking can alter the temperature , pulse respirations, and blood pressure by increasing each vital sign .

Answer 16

4,5

Question 17

The patient has been hospitalized after a severe head injury . What is most likely the reason for the patient having difficulty in maintaining a normal body temperature when there is no infection present ?

1. Choosing the wrong time of day to obtain vital signs
2. Errors by the nurse in measuring temperature
3. Increased vasodilation of the superficial vessels contributing to excess heat loss
4. The patient’s head injury causing interference with the function of the hypothalamus

Answer 17

4

Question 18

A pulse deficit provides information about the heart’s ability to adequately perfuse the body . What is the definition of a pulse deficit ?

1. The difference between the radial and the apical pulse rates
2. The digital pressure felt when taking radial and ulnar pulses
3. The amount of pressure felt when taking radial and ulnar pulses
4. The difference between the systolic and the diastolic blood pressure readings

Answer 18

1

Question 19

The nurse finds that the patient’s oral temperature is 98.8 F (37.1 C ). What is the next nursing action ?

1. Administer an antiemetic drug .
2. Offer the patient an additional blanket .
3. Report that the patient’s temperature is normal
4. Compare this with the patient’s baseline .

Answer 19

3

Question 20

The unlicensed assistive personnel reports that the patient is feeling “funny .” What is the nurse’s first action ?

1. Notify the health care provider .
2. Obtain the patient’s vital signs yourself
3. Delegate the assistant to retake the vital signs .
4. Tell the assistant to keep assessing the patient and report any further symptoms .

Answer 20

2

Question 21

The nurse is taking vital signs measurements and notes that the patient has a strong radial pulse that diminishes in intensity and that there are interruptions in rhythm about every four to six beats . What is the next action of the nurse ?

1. Report the findings to a health care provider
   .2. Measure a 60 -second apical pulse .
2. Connect the patient to a cardiac monitor .
3. Obtain a 60 -second apical - radial pulse

Answer 21

2

Question 22

When documenting a patient’s blood pressure , is the systolic pressure recorded ?

1. the first sound
2. the second Korotkoff sound
   3.At the fourth sound
   4.At the Korotkoff sound

Answer 22

1

Question 23

Which of measuring temperature reveals core temperatureall that apply) ?

1.Skin 2.Temporal 3.Oral 4.Axillary 5.Tympanic

Answer 23

2,5

Question 24

The nurse is providing discharge teaching to a who recently has been diagnosed with a cardiac condition teaching this patient how to assess the pulse , which is the best for the to teach ?

1.Radial artery 2. Pedal artery 3. Brachial artery 4. Femoral artery

Answer 24

1

Question 25

When teaching the patient about monitoring his own pulse , the nurse informs the patient that the pulse may be elevated by which of the following ? (Select all that apply

1. Taking beta blockers
2. Fever
3. Sleeping
4. Standing up too quickly
   5.Acute pain

Answer 25

2,5

Question 26

The nurse begins to measure the blood pressure of an adult . The patient says that his doctor has instructed him to always use a large cuff . What is a reason for using a large cuff ?

1. A blood pressure cuff that is too small gives inaccurately high readings .
2. A blood pressure cuff that is too small likely injures the brachial artery
3. Large cuffs are typically more accurate on adults than normal -size cuffs
4. Normal -size cuffs should be used for pediatric patients .

Answer 26

1

Question 27

The nurse is developing a care plan for a patient taking a diuretic to treat fluid retention . The nurse knows that weighing the patient on a daily basis willassist in monitoring the effectiveness of the medication because a weight of 1 kg indicates a fluid loss of how much ?

Answer 27

1 liter

Question 28

Online book 1-10

Answer 28

do online

Question 29

A nurse is auscultating a client’s apical pulse to listen to the S1 and S2 heart sounds. heart sounds are heard when which of the following occurs?

-When the atria contracts vigorously
-As the ventricular walls contract
-When the semilunar valves close
-As the mitral valve snaps open

Answer 29

-When the semilunar valves close

Question 30

A nurse is preparing to record the difference between a client’s systolic and diastolic blood pressureWhich of the following terms defines this Information when documenting?

-Auscultatory gap
-Pulse pressure
-Orthostatic hypotension
-pulse deficit

Answer 30

Pulse pressure

Question 31

A nurse is preparing to auscultate a client’s apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope?

A. Over the right midclavicular line
B. Over the angle of Louis
C. Overt the fifth intercostal spce at the left midclavicular line
D. Over the suprasternal notch

Answer 31

C

Question 32

A client is collecting data about a client’s respiratory condition. Which of the following actions should the nurse take to determine the depth of the client’s respiration?

A. Observe the degree of chest-wall movement during inspiration and expiration.
B. Count how many breathing cycles are observed per minute.
C. Notice whether or not expiration takes longer than inspiration.
D. Measure the precise amount of air the client takes in and breathes out.

Answer 32

A

Question 33

A nurse is assessing a client’s respiration. Which of the following actions should the nurse take?

A. Have the client lie flat in bed with their head on a pillow.
B. Elevate the head of the client’s bed 45 degrees to 60 degrees.
C. Encourage the client to breathe shallowly.
D. Ask the client to take several deep breaths prior to the assessment.

Answer 33

B

Question 34

A nurse is preparing to measure a client’s vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (Select all that apply.)

• The client who has a BMI of 35
• The client has had nausea for 2 days
• The client is reporting a “stuffy” nose
• The client has been fasting for blood tests.
• The client is taking digoxin for an irregular heart rate
• The client had a mastectomy 2 years ago

Answer 34

• The client who has a BMI of 35
• The client is reporting a “stuffy” nose
• The client is taking digoxin for an irregular heart rate
• The client had a mastectomy 2 years ago

Question 35

A nurse is preparing to obtain a client’s blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?

A. Obtain the reading in the early morning.
B. Use a cuff of the appropriate size for the client.
C. Assist the client to the bathroom to avoid.
D. Apply the cuff loosely around the client’s arm.

Answer 35

B

Question 36

A nurse obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider?

A. Oral temperature 37.8 C (100 F)
B. Respirations 30/min
C. BP 148/88 mm Hg
D. Radial pulse rate 45 beats/30 seconds

Answer 36

B

Question 37

A nurse is taking an adult client’s temperature rectally. Which of the following actions should the nurse take?

A. Rotate the probe if any resistance is met as the thermometer is inserted.
B. Insert the probe to aim at the client’s pelvic area.
C. Dip the probe about 0.58 cm (2 in) into a tube of lubricant.
D. Insert the probe about 2.5 cm (1 in) into the client’s anus.

Answer 37

D

Question 38

A nurse is establishing baseline for a client’s respirationsWhich of the following actions should the nurse take?

• Instruct the client to breathe in and to exhale out as they normally do
  -Count the client’s respirations for 15 seconds then multiply by 4
  -Determine if the client has a history of any chronic respiratory problems
  -Observe the client’s chest movements while appearing to assess their pulse

Answer 38

-Observe the client’s chest movements while appearing to assess their pulse

Question 39

A nurse is measuring a client’s temperature orally. Which of the following actions should the nurse take?

-Place the probe in the posterior lingual pocket lateral to the midline
.- Rest the probe on the lower lingual frenulum
-Place the probe centrally on top of the client’s tongue .
-Rest the probe under the tongue just beyond the client’s teeth.

Answer 39

-Place the probe in the posterior lingual pocket lateral to the midline

Question 40

A nurse is obtaining a client’s blood pressure and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to?

A. It corresponds to the client’s systolic pressure.
B. It is the second diastolic pressure to record.
C. It is the loudest of the Korotkoff sounds.
D. It might not follow with a fifth Korotkoff sound.

Answer 40

D

Question 41

A nurse is obtaining a client’s vital signs. the client has a new onset of a temp of 39C(102 F). Which of the following other vital signs should the nurse expect?

A. An elevated pulse rate
B. A decreased blood pressure
C. An elevated blood pressure
D. A decreased pulse rate

Answer 41

A

Question 42

A nurse is preparing to use a tympanic thermometer to acquire a client’s temperature . Which of the following actions should the nurse take to ensure an accurate reading?

-Attach the disposable probe cover
-Assess the external ear for redness
-Pull the pinna back and upward gently
-Replace the thermometer in its charger

Answer 42

-Pull the pinna back and upward gently

Question 43

A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.)

A. Address the client with the appropriate title and their last name .
B. Use a mix of open- and closed-ended questions.
C. Reduce environmental noise.
D. Have the client complete a printed history form.
E. Perform the general survey before the examination.

Answer 43

Ati book 2 Chapter 26

b,c,e

Question 44

A nurse in a provider’s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.)

A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

Answer 44

Ati book 2 Chapter 26

a,b,c

Question 45

A nurse is collecting data for a client’s comprehensive physical examination. After inspecting the client’s abdomen, which of the following skills of the physical examination process should the nurse perform next?

A. Olfaction B. Auscultation C. Palpation D. Percussion

Answer 45

Ati book 2 Chapter 26

b

Question 46

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client’s age? (Select all that apply.)

A. Expect the session to be shorter than for a younger client.
B. Plan to allow plenty of time for position changes.
C. Make sure the client has any essential sensory aids in place .
D. Tell the client to take their time answering questions .
E. Invite the client to use the bathroom before beginning the examination

Answer 46

Ati book 2 Chapter 26

b,c,d,e

Question 47

A nurse in a provider’s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature?

A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

Answer 47

Ati book 2 Chapter 26

C

Question 48

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3C (101F), pulse rate 114/min , and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take ? (Select all that apply .)

A. Obtain culture specimens before initiating antimicrobials .
B. Restrict the client’s oral fluid intake.
C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.

Answer 48

c,e

Question 49

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
A. “Do not measure the client’s temperature rectally.”
B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.”
C. “Do not let the client know you are counting their respirations .”
D. “ Let the client rest for 5 minutes before you measure their blood pressure .”

Answer 49

a

Question 50

A nurse is instructing a group of assistive personnel in measuring a client’s respiratory rate . Which of the following guidelines should the nurse include ? ( Select all that apply .)

A. Place the client in semi- Fowler’s position .
B. Have the client rest an arm across the abdomen .
C. Observe one full respiratory cycle before counting the rate .
D. Count the rate for 30 sec if it is irregular
E. Count and report any sighs the client demonstrates .

Answer 50

a,b,c

Question 51

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?

A. Request a prescription for an antihypertensive medication .
B. Ask the client if they are having pain .
C. Request a prescription for an antianxiety medication .
D. Return in 30 min to recheck the client’s blood pressure .

Answer 51

b

Question 52

A nurse is performing an admission assessment on a client. The nurse determines the client’s radial pulse rate is 68 / m * in and the simultaneous apical pulse rate is 84 / m * in What is the client’s pulse deficit?

Answer 52

16 min