Week 1 Material + EAQ

Question 1

Subjective VS Objective data

Subjective
-how is the patient __________ [pain level, symptoms, fatigue, etc]
-view from ___________

Objective
-What the _______________________
-I see the patient is breathing hard
-I gather info from labs

Answer 1

Subjective
-how is the patient feeling [pain level, symptoms, fatigue, etc]
-view from the patient

Objective
-What nurse observes and gathers
-I see the patient is breathing hard
-I gather info from labs

Question 2

Sources of patient data

Client
Family/Sig. others
______________ team
___________ records
diagnostic data

Answer 2

Client
Family/Sig. others
Health care team
medical records
diagnostic data

Question 3

Methods of assessment

__________ centered interview
_________ experience
Environment
Nursing ________ history

Answer 3

Patient centered interview
Nurse’s experience
Environment
Nursing health history

Question 4

Nursing health history

-___________ info
-_________ for seeking care
-client __________
-Present illness (PQRST)
-Health and family history
-Pyschosocial history
-spiritual health
-review of systems
-behavior observation

Answer 4

-Biographical info
-Reason for seeking care
-client expectations
-Present illness (PQRST)
-Health and family history
-Pyschosocial history
-spiritual health
-review of systems
-behavior observation

Question 5

Medical diagnosis VS Nursing diagnosis

Medical diagnosis:
The identification of a disease condition base on specific evaluation of _____________________

Nursing diagnosis:
A clinical _____________ about the client in response to an actual or potential __________ problem

Answer 5

Medical diagnosis:
The identification of a disease condition base on specific evaluation of signs and symptoms

Nursing diagnosis:
A clinical judgment about the client in response to an actual or potential health problem

Question 6

Actual (Problem Focused) Nursing Diagnosis Describes:
undesirable human response to existing problems or concerns of a patient.

Risk Nursing Diagnosis Describes:
human responses to health conditions/life processes that ________________

Answer 6

Actual (Problem Focused) Nursing Diagnosis Describes:
undesirable human response to existing problems or concerns of a patient.

Risk Nursing Diagnosis Describes:
human responses to health conditions/life processes that may develop

Question 7

ABC [priorities]

?

Answer 7

Airway
Breathing
Circulation

Question 8

Expected outcomes need to be

SMAR

?

Answer 8

Specific
Measurable
Attainable
Realistic

Question 9

Vital Signs

• Body ______________
• Pulse
• ___________/Oxygen Saturation
• _______ Pressure
• _______ (The 5th Vital Sign)

Answer 9

• Body Temperature
• Pulse
• Respiration/Oxygen Saturation
• Blood Pressure
• Pain (The 5th Vital Sign)

Question 10

Normal temperature range

◦ ______________________

or

36* C to 38* C

Answer 10

96.8* F to 100.4* F

Question 11

Factors Affecting Body Temperature

-Age
-Exercise
- _________ level
-Circadian rhythm
- Environment
- ___________ alterations
◦ Fever/Pyrexia/FUO
◦ Heatstroke
◦ ______ Exhaustion

Answer 11

-Age
-Exercise
- Hormonal level
-Circadian rhythm
- Environment
-Temperature alterations
◦ Fever/Pyrexia/FUO
◦ Heatstroke
◦ Heat Exhaustion

Question 12

Pulse

-An indicator of _________ status
-Electrical impulses originate from the _______________
-Cardiac output = heart rate * stroke volume
-Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume

Answer 12

-An indicator of circulatory status
-Electrical impulses originate from the sinoatrial (SA) node
-Cardiac output = heart rate * stroke volume
-Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume

Question 13

Arterial Blood Pressure:
Force exerted on __________________

Answer 13

Force exerted on walls of an artery

Question 14

Factors Influencing Blood

• Age
• Stress
• Ethnicity/Genetics
• Gender
• Daily Variation
• Medications
• Activity, weight
  -Smoking

Answer 14

• Age
• Stress
• Ethnicity/Genetics
• Gender
• Daily Variation
• Medications
• Activity, weight
  -Smoking

Question 15

Hypertension
-More ___________ than hypotension
- ___________ of walls
- Loss of elasticity
- Family history
- Risk factors

Hypotension
-90 mm Hg
- __________ of arteries
- ______ of blood volume
- __________ of blood flow to vital organs
- Orthostatic/postural

Answer 15

Hypertension
-More common than hypotension
- Thickening of walls
- Loss of elasticity
- Family history
- Risk factors

Hypotension
-90 mm Hg
- Dilation of arteries
- Loss of blood volume
- Decrease of blood flow to vital organs
- Orthostatic/postural

Question 16

What is pain?

An _____________ ____________ and emotional experience associated with actual or potential tissue damage..

whatever the _________________________________ says it is

Nurses are ___________ and ___________ responsible to manage pain and relieve suffering

Answer 16

An unpleasant sensory and emotional experience associated with actual or potential tissue damage..

whatever the person experiencing pain says it is

Nurses are ethically and legally responsible to manage pain and relieve suffering

Question 17

Pain Assessment

PQRST
?

Answer 17

◦ Provokes/Pallaiative
◦ Quality
◦ Region/Radiation
◦ Severity
◦ Timing

Question 18

Pulse (Acceptable range)

Answer 18

60 to 100 beats/min, strong and regular

Question 19

Pulse oximetry (SpO2) Acceptable range

Answer 19

Normal: SpO2 ≥95%

Question 20

Respirations acceptable range

Answer 20

12 to 20 breaths/min, deep and regular

Question 21

Blood pressure acceptable range

Answer 21

Systolic <120 mm Hg
Diastolic <80 mm Hg

Pulse pressure: 30 to 50 mm Hg

Question 22

Capnography (EtCO2) acceptable range

Answer 22

Normal: 35-45 mm Hg

Question 23

Which assessing technique involves tapping a client’s skin with the fingertips to cause vibrations in the underlying tissues?
1 Palpation
2 Inspection
3 Percussion
4 Auscultation

Answer 23

3 Percussion

Percussion is the process of tapping the body parts with the fingers or hands to determine the consistency and borders of the body organs. Palpation is the act of feeling with the hand by applying pressure to the body surface to determine the condition of the skin and underlying tissues. Inspection is the process of visual observation of the body during physical examination. Auscultation means to listen to the internal sounds of the body.

Question 24

Components of a Nursing Diagnosis

-__________ Label (NANDA-I)
-________ Factors (r/t=related to)
- Definition (NANDA-I)
- ____________ Condition
-Support of the Diagnostic Statement

Answer 24

-Diagnostic Label (NANDA-I)
-Related Factors (r/t=related to)
- Definition (NANDA-I)
- Associated Condition
-Support of the Diagnostic Statement

Question 25

__________ Diagnosis Examples

• Impaired comfort r/t itching.
• Risk for electrolyte imbalance r/t renal dysfunction.
• Disturbed body image r/t lesions on body.
• Deficient fluid volume r/t active fluid loss as evidenced by (aeb) excessive diuresis.

Answer 25

Nursing

Question 26

Peripheral resistance.

The BP depends on peripheral vascular resistance.

Peripheral vascular resistance is the _________________________ determined by the tone of vascular musculature and diameter of blood vessels.

The smaller the lumen of a vessel, the greater is the peripheral vascular resistance to blood flow.

As resistance rises, arterial BP rises. When vessels dilate and resistance falls, arterial BP falls.

Answer 26

resistance to blood flow

Question 27

The nurse assessed a client’s pulse rate and recorded the score as 3+. Which describes the strength of the pulse?
1 Strong
2 Bounding
3 Expected
4 Diminished

Answer 27

1 Strong

Question 28

Which physical skin finding would the nurse associate with opioid abuse?

Answer 28

Needle markings

Question 29

Which relatable site would the nurse utilize to assess a client for jaundice?

Answer 29

Sclera

Question 30

Which part of the client’s body would the nurse assess to confirm a diagnosis of frostbite?

Answer 30

fingertips, earlobes

Question 31

Which condition would the nurse suspect when a client, who underwent a physical examination two days ago, reports itching?

Answer 31

Contact dermatitis

Question 32

After assessing the muscle functionality of a client, the nurse assigns a grade of F(fair) on the Lovett scale,=. Which statement describes the muscle functionality of this client?

Answer 32

Full range of motion with gravity.

Question 33

When interpreting findings from a pain assessment, which factors would the nurse consider the most significant influences on a client’s perception of pain?

Answer 33

Previous experience and cultural values

Question 34

When assessing a client’s blood pressure, obtained via the client’s unsupported left arm, which reading error would the nurse expect?

Answer 34

False high reading

Question 35

In which situation would the nurse consider family members as the primary source of information?

Answer 35

The client is an infant or child.
The client is brought in as an emergency.
The client is critically ill and disoriented.

Question 36

To prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor?

Answer 36

Fluid and electrolyte balance

Question 37

For which age group would the nurse expect the occurrence of chronic illness to be the highest?

Answer 37

older adults

Question 38

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water soluble vitamin?

Answer 38

Biotin
Niacin
Folic Acid
Riboflavin
Vitamin C

Question 39

When gathering data fro a client’s health history, which intellectual factor would the nurse consider as a dimension?

Answer 39

attention span

Question 40

Which factor would the nurse assess for a client reporting constipation?

Answer 40

Diet
Fluid intake
Use of laxatives
Date of last BM
Use of opioid pain meds

Question 41

oranges and other citrus fruits contain:

Answer 41

potassium

Question 42

Which physical change would the nurse observe in a client with malnutrition?

Hypotension
Dry, dull hair
Abdominal edema
Delayed wound healing
Depletion of muscle mass

Answer 42

Hypotension
Dry, dull hair
Abdominal edema
Delayed wound healing
Depletion of muscle mass

all of the above

Question 43

Which clinical finding would the nurse associate with hypokalemia?

Answer 43

Muscle weakness

Question 44

Which pulse site would the nurse use to preform the Allen test?

Answer 44

Ulnar

Question 45

The nurse providing primary preventive care at a community health care center focuses on which type of activity?

Answer 45

Promoting health in healthy individuals

Question 46

Which position would the nurse utilize to assess the musculoskeletal system, but contraindicated for clients experiencing chronic respiratory disease?

Answer 46

prone position

Question 47

__________ refers to circulation of the skin

Answer 47

Vascularity

Question 48

During a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position?

Answer 48

female genitalia

Question 49

__________ refers to circulation of the skin

Answer 49

Vascularity

Question 50

________ indicates fluid build up in the tissues

Answer 50

Edema

Question 51

Which assessment finding of the skin refers to elasticity?

Answer 51

Turgor

Question 52

Which physical assessment technique involves listening to the sounds of the body?

Answer 52

Auscultation

Question 53

Which statement describes the percussion technique?

Answer 53

Tapping the skin with the fingertips to vibrate underlying tissues.

Question 54

In which order would the nurse apply the nursing process while providing care for clients ?
diagnosis,
implementation,
Assessment,
evaluation
planning,

Answer 54

Assessment,
diagnosis,
planning,
implementation,
evaluation

Question 55

Which degree of edema will result in a 6-mm deep indentation upon pressure application?
a. 4+
b. 3+
c. 2+
d. 1+

Answer 55

b. 3+

Question 56

The nurse noticed the respiratory rate a regular and slow while assessing a client. Which would be the condition of the client?
a. apnea
b. bradypnea
c. tachypnea
d. hyperpnea

Answer 56

b. bradypnea

Question 57

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved?

1. Mastoid
2. Occipital
3. Submental
4. Pre-auricular

Answer 57

4. Pre-auricular

Question 58

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?
1 Visceral pain
2 Somatic pain
3 Referred pain
4 Intractable pain

Answer 58

1. Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity.

Question 59

Koilonychia is the concave ________ on the nail.

Answer 59

curves

Question 60

Paronychia is the ____________ of the skin at the base of nail.

Answer 60

inflammation

Question 61

In clubbing, there is a change in the angle between the nail and the nail base that is larger than ____ degrees.

Answer 61

180

Question 62

A nurse is assessing a client’s nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition does the nurse suspect?
a. clubbing
b. paronychia
c. koilonychia
d. normal finding

Answer 62

d. normal finding

Question 63

The nurse finds that the client’s fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?

Answer 63

Remittent

Question 64

Which would the nurse document for a client with drooping of the eyelid over the pupil?

Answer 64

Ptosis

Question 65

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse?
a. bruit
b. ectropion
c. entropion
d. borborygmi

Answer 65

a. bruit

A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

Question 66

Which characteristic would the nurse associate with collaborative problems experienced by a client?

A. they are the identification of a disease condition
B. they include problems treated primarily by nurses
C. they are identified by the primary health care provider
D. they are identified by the nurse during the nursing diagnosis stage

Answer 66

d) ID by nurse during diagnostic process

The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client’s health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

Question 67

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the “related to” factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?

1 The nurse notes nonverbal signs of discomfort.
2 The nurse observes the client’s position in bed.
3 The nurse asks the client to explain the surgery.
4 The nurse asks the client to rate the severity of pain

Answer 67

3 The nurse asks the client to explain the surgery.

The nurse must assess the client’s knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client’s positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

Question 68

The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source?
a. X Ray reports
b. severity of pain
c. results of blood work
d. family caregiver interview

Answer 68

Severity of pain [from client]

Question 69

what definition does the WHO use to define health?

Answer 69

a state of complete physical, mental and social well-being

Question 70

The nurse assessed a client’s pulse rate and recorded the score as 3+. Which describes the strength of the pulse?
1 Strong
2 Bounding
3 Expected
4 Diminished

Answer 70

1 Strong

Question 71

Body temperature is regulated by the ______________ , a small endocrine gland in the center of the brain.

Answer 71

hypothalamus

Question 72

Blood pressure is a peripheral measure of function of the cardiac system.

More specifically, it is the _____________________ against the artery wall during contraction and relaxation of the ventricles.

Answer 72

force of the blood

Question 73

Blood pressure is measured using two pressure readings—systolic (top number) and diastolic (bottom number).

Systolic pressure is the force exerted when the ventricles __________. This measure depends on the cardiac output, blood volume, and arterial compliance.

The diastolic pressure is the force exerted by peripheral vascular resistance when the ventricles are ____________ and the heart is filling.

Answer 73

Systolic pressure is the force exerted when the ventricles contracts. This measure depends on the cardiac output, blood volume, and arterial compliance.

The diastolic pressure is the force exerted by peripheral vascular resistance when the ventricles are relaxed and the heart is filling.

Question 74

_____________________ : systematic observation, measurement, experiment, formulation, testing, and modification of hypothesis

Answer 74

Scientific method

Question 75

___________________ : defining a problem, determining cause of problems, identifying, prioritizing and selecing alternatives for a solution; implementing solution

Answer 75

Problem solving

Question 76

_____________________ : making choices by identifying a decision, gathering information, and assessing alternative resolutions

Answer 76

Decision making

Question 77

______________________ and inference: dynamic thinking process that leads to identification of a hypothesis that best explaiins the clinical evidence

Answer 77

Diagnostic reasoning

Question 78

__________________________: best practice (the evidence, the research), awareness of the current situation and environment, and knowledge of the patient

Answer 78

Clinical decision making

Question 79

Critical thinking: always think in the context of the ___________, NOT just the norms

______________ there is a problem

___________ the clinical data

___________ the data and review assumptions and evidence

_____________: draw a conclusion

Answer 79

Critical thinking: always think in the context of the patient, NOT just the norms

Recognize there is a problem

Analyze the clinical data

Evaluate the data and review assumptions and evidence

Explanation: draw a conclusion

Question 80

ADPIE:

Answer 80

Assessment
diagnosis
Planning
Implementation
Evaluating

Question 81

_______________ : the collection, verification, and analysis of data

Tools:
Interview (subjectiver data)
Nursing health history: reason for seeking care, hisory
Physical examination (objective data) labs, observation, nursing judgements
Documentation: last component of assessment, legal requirement
Concept mapping: visually represents connection between client’s health problems

Answer 81

Assessment

Question 82

_________________________ : a clinical judgement about the client in response to an actual or potential health problem

Actual: existing

At risk: potential

Components:
Diagnostic label (NANDA-I)
R/T
Definition (NANDA-I)
Risk factors
Support of diagnostic statement

Answer 82

Nursing diagnosis

Question 83

________: a broad statement that describes the desired change in a client’s condition or behavior

Guideleines: ________ centered, singular, observable. measurable, time limited, realistic

Answer 83

Goal: a broad statement that describes the desired change in a client’s condition or behavior

Guideleines: client centered, singular, observable. measurable, time limited, realistic

Question 84

______________________: measurable criteria to evaluate goal achievement

Determine when a specific, client centered goal has been met

Answer 84

Expected outcome

Question 85

Implementation process

__________!

___________ client
review care plan
organize resources
Anticipate/prvent complications

Answer 85

Implementation process

REASSESS!

Reassess client
review care plan
organize resources
Anticipate/prvent complications

Question 86

Significance of vital signs

Answer 86

help establish Pt’s baseline + Detect overall changes in their health

Question 86

__________- on-going process

Positive evaluation: outcomes are met, understand that interventions were successful

5 elements of evaluation:

Identify evaluative criteria and standards
collect _______
interpret/ summarize ___________
Document findings and clinical judgements
Terminate, continue, or revise care plan

Answer 86

Evaluation

Identify evaluative criteria and standards
collect data
interpret/ summarize results
Document findings and clinical judgements
Terminate, continue, or revise care plan

Question 87

What is the major health problem resulting from a pulse deficit?

A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion

Answer 87

C. Decreased cardiac output

Question 88

What should the nurse do when a pulse deficit is suspected?

A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.
B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.
C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute.
D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.

Answer 88

D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.

Question 89

Which action should the nurse perform after identifying a pulse deficit?

A. Reassess the apical-radial pulse in 5 minutes.
B. Assess the patient for signs of decreased cardiac output.
C. Notify the primary health care provider of the pulse deficit.
D. Initiate interventions directed toward managing the patient’s symptoms.

Answer 89

B. Assess the patient for signs of decreased cardiac output.

Question 90

You have the following information:
Oral temperature–36.8°C.
Radial Pulse–112 weak, thready
Apical pulse–117 regular
Respirations–24 regular
Blood Pressure–104/56 right arm
–102/50 left arm

What is the pulse deficit?

A. 2
B. 5
C. 6
D. 48

Answer 90

B. 5

Question 91

What is the purpose of performing hand hygiene?

A. To prevent the spread of infection
B. To prevent staff contact with infections
C. To keep patients from exposure to bacteria or viruses
D. To eliminate the need to wear gloves when providing care

Answer 91

A. To prevent the spread of infection

Question 92

Which of the following is an early manifestation of decreased cardiac output?

A. Fatigue
B. Substernal pain
C. Nail bed cyanosis
D. Shortness of breath

Answer 92

A. Fatigue

Question 93

When is it appropriate to use an alcohol-based hand rub to perform hand hygiene?

A. If exposure to anthrax spores is suspected
B. If gloves were worn during patient contact
C. If the hands are not visibly soiled
D. If the hands are dry or chapped

Answer 93

C. If the hands are not visibly soiled

Question 94

When washing the hands with soap and water, which procedure should the nurse follow?

A. Turn on and adjust the water until it feels cool.
B. Keep your hands above your elbows while washing.
C. Turn off the faucet with your clean dry hand.
D. Use plenty of lather and friction and wash for at least 15 to 20 seconds.

Answer 94

D. Use plenty of lather and friction and wash for at least 15 to 20 seconds.

Question 95

When using soap and water to perform hand hygiene, how much soap should the nursing assistant use?

A. About one drop
B. About two pumps
C. About 1 teaspoon
D. About 1 tablespoon

Answer 95

C. About 1 teaspoon

Question 96

As part of performing hand hygiene, how should the nursing assistant dry the hands?

A. Let the hands air dry.
B. Use clean, dry paper towels.
C. Use a clean, dry cloth.
D. Place the hands under a hot-air hand dryer.

Answer 96

B. Use clean, dry paper towels.

Question 97

During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?

A. Assessment of peripheral blood perfusion
B. Establishment of a baseline as part of the patient’s vital signs
C. Assessment of the patient’s cardiovascular disease risk
D. Determination of oxygen saturation

Answer 97

B. Establishment of a baseline as part of the patient’s vital signs

Question 98

What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?

A. Place the patient in the lateral (side-lying) position before measuring the pulse.
B. Apply gloves with each patient before measuring the pulse.
C. Document whether the patient’s pulse is bounding or has diminished.
D. Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.

Answer 98

D. Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.

Question 99

What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?

A. Reassess the pulse for 1 full minute.
B. Assess the patient for a pulse deficit.
C. Wait 5 minutes, and then reassess the pulse.
D. Review documentation regarding an irregular rhythm.

Answer 99

B. Assess the patient for a pulse deficit.

Question 100

Inadequate oxygenation to the body will cause the radial pulse to become:

A. Tachycardic
B. Bradycardic
C. Irregular
D. Bounding

Answer 100

A. Tachycardic

Question 101

Which action would best assess the effect of exercise on a patient’s radial pulse measurement?

A. Measuring the patient’s radial pulse before and after exercise.
B. Assessing the patient’s radial pulse 30 minutes after exercise.
C. Comparing the patient’s radial and apical pulses after exercise.
D. Comparing the patient’s pre-exercise radial and post-exercise apical pulses.
Submit Test

Answer 101

A. Measuring the patient’s radial pulse before and after exercise.

Question 102

What is the major health problem resulting from a pulse deficit?

A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion

Answer 102

C. Decreased cardiac output

Question 103

During an examination of a pediatric patient who was admitted for postoperative pain management, the nurse assesses a decreased respiratory rate. What should the nurse consider as the most likely cause for a decrease in the rate?

A. Fever
B. Anxiety
C. Opioid analgesic
D. Fear

Answer 103

C. Opioid analgesic

Question 104

Which statement by the patient’s parent indicates the family needs further education about accurate respiratory rate measurement?

A. “My child is breathing fine; the monitor numbers have been good all day.”
B. “Whenever my child needs pain medicine, my child’s breathing is very shallow and fast.”
C. “I’ve noticed that when my child has a fever, my child’s breathing is faster.”
D. “I will hold my child and give the pacifier so that you can listen to the breathing.”

Answer 104

A. “My child is breathing fine; the monitor numbers have been good all day.”

Question 105

When assessing an accurate respiratory rate for a 3-month-old patient, what should the nurse directly observe?

A. Abdominal movement for 1 minute
B. Chest movement for 1 minute
C. Abdominal movement for 30 seconds
D. Chest movement for 30 seconds

Answer 105

A. Abdominal movement for 1 minute

Question 106

A nurse is caring for a 2-year-old patient with respiratory distress. The patient’s respiratory rate has been 50 breaths per minute, with intercostal retractions and nasal flaring for the past 45 minutes. The nurse now observes that the patient is sleepy, with a respiratory rate of 16 breaths per minute. The patient has received no pain medication. What must the nurse consider in performing a respiratory assessment of this patient?

A. The patient’s condition has improved.
B. The patient’s respiratory rate is normal for the patient’s age.
C. The patient’s respiratory rate indicates hyperpnea.
D. The patient may be in imminent respiratory failure.

Answer 106

D. The patient may be in imminent respiratory failure.

Question 107

A 2-week-old infant is displaying an irregular breathing pattern, with periodic increases in respiratory rate that return to normal. The patient is otherwise eating well and has no other signs of respiratory distress. What should the nurse tell the family about this breathing pattern during family teaching?

A. This is an indication of moderate respiratory distress.
B. The patient has signs of impending respiratory failure.
C. This breathing pattern is normal for the patient’s age.
D. The patient has an upper respiratory infection.

Answer 107

C. This breathing pattern is normal for the patient’s age.

Question 108

What must the pediatric nurse know about accurate respiratory measurements when monitoring for signs of changes in the work of breathing in an infant or child?

A. Infants and children have higher metabolic rates than adults.
B. Normal respiratory patterns in infants can be irregular.
C. Children have more areas for gas exchange in the lungs than adults.
D. Infants are less prone to respiratory infections than adults.

Answer 108

B. Normal respiratory patterns in infants can be irregular.

Question 109

What is the altered respiratory pattern that can be described as unpredictable, ataxic, irregular breathing?

A. Kussmaul
B. Hyperpnea
C. Tachypnea
D. Biot

Answer 109

D. Biot

Question 110

What is the median respiratory rate (breaths per minute) for an 8-year old patient?

A. 19
B. 20
C. 16
D. 24

Answer 110

B. 20

Question 111

The nurse is preparing to auscultate breath sounds for an infant. What is the first step taken?

A. Warm the bell of the stethoscope with the hand.
B. Place the stethoscope on the left side of the chest.
C. Position the infant with the head slightly elevated.
D. Place the stethoscope on the right upper chest.

Answer 111

A. Warm the bell of the stethoscope with the hand.

Question 112

The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?

A. Blood pressure cuff is too wide
B. Blood pressure cuff is too loose around the arm
C. Taking the blood pressure in an arm into which intravenous fluids are infusing
D. Arm is positioned above the level of the heart

Answer 112

B. Blood pressure cuff is too loose around the arm

Question 113

What would cause the nurse to delay the assessment of a patient’s blood pressure?

A. Patient is resting in bed, reading a book
B. Patient received medication within the last 10 minutes
C. Patient is visiting with family
D. Patient has just finished having a cigarette

Answer 113

D. Patient has just finished having a cigarette

Question 114

The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?

A. Minimize the effect of anxiety
B. Distract the patient
C. Listen for the second and third Korotkoff sounds
D. Confirm that the cuff was applied correctly

Answer 114

A. Minimize the effect of anxiety

Question 115

The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?

A. Follow your regular healthy diet.
B. Limit physical activity.
C. Ensure an adequate daily intake of sodium and fat.
D. Ensure that your diet has an adequate daily intake of calcium.

Answer 115

D. Ensure that your diet has an adequate daily intake of calcium.

Question 116

Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?

A. Use the left arm to take the blood pressure.
B. Use the right arm to take the blood pressure.
C. Do not take the blood pressure.
D. Use a lower extremity to take the blood pressure.

Answer 116

B. Use the right arm to take the blood pressure.

Question 117

A patient who was rescued from a pond is hypothermic and has been intubated. The patient’s blood pressure cannot be auscultated. Which technique using the probe is the best for measuring the patient’s blood pressure by Doppler ultrasound?

A. Apply 2 to 10 lb of pressure to the probe, depending on the depth of the vessel.
B. Use alcohol to moisten the area where the probe will be placed.
C. Place the probe at a 45-degree angle along the length of the vessel.
D. Place the probe directly over the femoral pulse.

Answer 117

C. Place the probe at a 45-degree angle along the length of the vessel.

Question 118

A systolic blood pressure measurement of 100 mm Hg is obtained from a patient with diabetes by using Doppler ultrasound. Which statement is correct regarding this blood pressure measurement?

A. Indicates a need for a vasodilator
B. May be erroneously low
C. Indicates the most accurate blood pressure
D. May be erroneously elevated

Answer 118

D. May be erroneously elevated

Question 119

During assessment of peripheral pulses in the left leg via a Doppler instrument, the dorsalis pedis pulse cannot be located. What is the most appropriate next step?

A. Attempt to find the dorsalis pedis pulse in the right leg.
B. Attempt to locate the posterior tibial pulse.
C. Attempt to locate the popliteal pulse.
D. Reattempt to locate the pulse after applying additional transmission gel.

Answer 119

B. Attempt to locate the posterior tibial pulse.

Question 120

Vascular sounds are not audible with the Doppler probe over the site where the brachial artery is palpable. What is the best way to assess the sensitivity of the instrument?

A. Use the probe to check own pulse.
B. Use bleach and hot water to clean the probe.
C. Change probes.
D. Press harder with the probe.

Answer 120

A. Use the probe to check own pulse.

Question 121

During assessment of a patient’s brachial pulse, a high-pitched sound is heard. The sound resembles a rushing wind and is cyclic with respirations. What is the best next step?

A. Reposition the probe until loud, pulsatile sounds are heard.
B. Increase the angle of the probe to 90 degrees.
C. Clean the probe and the skin thoroughly with alcohol.
D. Switch to the 2.25-MHz probe.

Answer 121

A. Reposition the probe until loud, pulsatile sounds are heard.

Question 122

What is a possible explanation for an artificially high reading obtained from an obese patient’s arm?

A. The cuff is too large for the extremity.
B. The cuff is too small for the extremity.
C. Resistance to pressure is generated by the heart.
D. The cuff is too snug for the extremity.

Answer 122

B. The cuff is too small for the extremity.

Question 123

Which is correct regarding Korotkoff phase 1 sounds?

A. Last sound heard after deflation of the cuff begins
B. Reflect the diastolic pressure
C. Sound muffled
D. First sound heard after slow deflation of the cuff begins

Answer 123

D. First sound heard after slow deflation of the cuff begins

Question 124

What instruction should be given to the patient before using Doppler ultrasound to obtain peripheral pulses?

A. “There is no pressure applied to the site when using the probe.”
B. “You need to remain still for the procedure.”
C. “You will be expected to move during the procedure.”
D. “Gel will be used to reduce transmission of the sound.”

Answer 124

B. “You need to remain still for the procedure.”

Question 125

Which is correct regarding size of a pediatric blood pressure cuff?

A. The length of the cuff bladder should be 40% of arm circumference.
B. The width of the bladder should be at least 80% of arm circumference.
C. The length of the cuff bladder should be 80% of arm circumference.
D. The width of the bladder should be at least 20% of arm circumference.

Answer 125

C. The length of the cuff bladder should be 80% of arm circumference.

Question 126

Which is a characteristic of arterial sounds?

A. Arterial sounds are loud and pulsatile.
B. Arterial sounds are muffled and pulsatile.
C. Arterial sounds resemble the sound of rushing wind.
D. Arterial sounds are high pitched.

Answer 126

A. Arterial sounds are loud and pulsatile.

Question 127

A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?

A. The patient rates his pain a 7 on a scale of 0 to 10.
B. The patient winces and guards the area as the nurse gently palpates the abdomen.
C. The patient is having trouble sleeping and has become irritable.
D. The patient is moaning softly and frowning, with a pinched expression on his face.

Answer 127

A. The patient rates his pain a 7 on a scale of 0 to 10.

Question 128

What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain?

A. “Let me know at least 30 minutes before you transport her so I can administer her analgesics.”
B. “Be sure to keep the room temperature high and the TV on at all times.”
C. “Be sure to tell me if you notice grimacing, guarding, or any unusual behavior.”
D. “I’ve given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.”

Answer 128

A. “Let me know at least 30 minutes before you transport her so I can administer her analgesics.”

Question 129

Which observation indicates that a patient’s analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?

A. The patient is seen quietly reading a magazine.
B. The patient rates her current pain as 3 out of 10 on the pain rating scale.
C. The patient is overheard telling her family that she is “feeling better today.”
D. The patient is observed sleeping, with a respiratory rate assessed at 18/minute, compared with 22/minute before the intervention.

Answer 129

B. The patient rates her current pain as 3 out of 10 on the pain rating scale.

Question 130

A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient?

A. Repainting her new apartment
B. Lifting moving boxes on and off of a truck
C. Performing neck, back, and shoulder exercises prescribed by a physical therapist
D. Performing yoga exercises from the patient’s favorite set of videotapes

Answer 130

C. Performing neck, back, and shoulder exercises prescribed by a physical therapist

Question 131

The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?

A. It is likely the patient is a drug seeker and has little or no pain.
B. The patient’s problem is more mental than physical.
C. The absence of physiological signs and symptoms is associated with chronic pain.
D. The patient’s pain cannot be accurately assessed until the patient has been treated for anxiety.

Answer 131

C. The absence of physiological signs and symptoms is associated with chronic pain.

Question 132

What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?

A. Place the patient in the Fowler’s position.
B. Wear sterile gloves during the process.
C. Insert the probe in the direction of the knees.
D. Use the probe with the red tip.

Answer 132

D. Use the probe with the red tip.

Question 133

Which of the following is contraindicated with taking a rectal temperature measurement?

A. Patient requires assistance to move to a side-lying position.
B. Patient has painful and swollen hemorrhoids.
C. Patient is incontinent of urine.
D. The last temperature recorded was 0.2° F above baseline.

Answer 133

B. Patient has painful and swollen hemorrhoids.

Question 134

Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6° F?

A. Assess for physical aches.
B. Assess skin temperature by touching the forehead.
C. Assess oral temperature 30 minutes after the agent is administered.
D. Assess skin color for signs of fever-related flushing.

Answer 134

C. Assess oral temperature 30 minutes after the agent is administered.

Question 135

Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment?

A. Leave the probe in place until the reading is complete.
B. Put on a new disposable probe cover for each patient.
C. Gently tug the pinna backward, up, and out before inserting the probe.
D. Check for any impacted cerumen in the ear.

Answer 135

C. Gently tug the pinna backward, up, and out before inserting the probe.

Question 136

Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?

A. An accurate temperature reading is obtained with moisture on the forehead.
B. Put on a disposable sensor cover before taking the temporal artery temperature.
C. Place the sensor flush on the patient’s forehead.
D. Obtain the temperature reading on the lower neck.

Answer 136

C. Place the sensor flush on the patient’s forehead.

Question 137

The general assessment of a 6-month-old patient who appears malnourished reveals uncleanliness and a flat, balding occiput. What do these findings indicate about this infant?

A. Physical abuse
B. Prematurity
C. Neglect
D. A congenital abnormality

Answer 137

C. Neglect

Question 138

During the general assessment of a 2-year-old patient, a foul odor emanating from the right naris is noted. What is the most likely cause of this odor?

A. A foreign body
B. An upper respiratory infection
C. Epistaxis
D. Allergies

Answer 138

A. A foreign body

Question 139

What is the best way to gain the cooperation of a 5-year-old patient during a physical examination?

A. Engage in a conversation with the patient to encourage relaxation.
B. Give the patient a treat before beginning the examination in exchange for cooperation.
C. Use a stuffed animal to demonstrate the examination.
D. Have the patient draw a picture as a distraction technique during the examination.

Answer 139

C. Use a stuffed animal to demonstrate the examination.

Question 140

A 4-year-old patient recognizes the parent, says “tree” when looking out the window, and states, “I am four,” when asked about age. How should the nurse document orientation for this patient?

A. Unable to determine
B. Oriented × 3
C. Awake and alert
D. Appropriate for developmental level

Answer 140

D. Appropriate for developmental level

Question 141

During the physical assessment of a patient with diabetes mellitus, the nurse palpates nonpainful localized areas of hardness in the midepigastric area of the patient’s abdomen. What instruction should the nurse provide the family regarding this finding?

A. Rotate injection sites
B. Increase fiber intake
C. Increase fluid intake
D. Use smaller-gauge needles

Answer 141

A. Rotate injection sites

Question 142

While counting a patient’s respirations, the nurse recognizes respiratory distress. Which assessment should the nurse conduct next?

A. Circulatory system
B. Remaining vital signs
C. Respiratory system
D. Head and neck

Answer 142

C. Respiratory system

Question 143

In which order should the nurse assess an infant’s vital signs?

A. Respiration, temperature, heart rate
B. Heart rate, respiration, temperature
C. Temperature, heart rate, respiration
D. Respiration, heart rate, temperature

Answer 143

D. Respiration, heart rate, temperature

Question 144

Which approach to physical examination is appropriate when assessing a school-age patient?

A. Gain cooperation through distraction.
B. Teach about body function and care.
C. Make up a story about procedure.
D. Allow equipment inspection.

Answer 144

B. Teach about body function and care.

Question 145

Which condition should the nurse include in a list of common causes of hearing loss in school-age patients when providing patient and family education?

A. Impacted cerumen
B. Foreign body in the ear canal
C. Repeated inner ear infection
D. Noise-induced loss

Answer 145

A. Impacted cerumen

Question 146

Which approach should the nurse use during the physical examination of an adolescent patient?

A. Emphasize normalcy of development.
B. Suggest family presence.
C. Ask the parent to voice any concerns.
D. Use prone positioning.

Answer 146

A. Emphasize normalcy of development.

Question 147

Pulse strengths

0- _______
1- diminished/ barely palpable
2- ________________
3- full/strong
4- _________ / very strong

Answer 147

0- absent
1- diminished/ barely palpable
2- normal/ expected
3- full/strong
4- bounding/ very strong