Week 2

Question 1

What is the primary purpose of initially assessing an apical pulse?

Answer 1

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

Question 2

What instruction should the nurse give an unregulated care provider (UCP) regarding the appropriate technique when measuring the adult patient’s apical pulse?

Answer 2

Place your stethoscope at the fifth intercostal space over the left midclavicular line.

Question 3

Which action would take priority if a patient’s apical pulse has an irregular rhythm?

Answer 3

Reassess the pulse for 1 full minute.

Question 4

Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?

Answer 4

“The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom.”

Question 5

The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?

Answer 5

Comparing the patient’s post-crying apical pulse rate with their baseline or previous rate

Question 6

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

Answer 6

Decreased cardiac output

Question 7

Bradycardia

Answer 7

is a pulse rate less than 60 beats/minute.

Question 8

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

Answer 8

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

Question 9

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

Answer 9

Assess the patient for signs of decreased cardiac output

Question 10

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?

Answer 10

Apical - pulse rates
5

Question 11

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

Answer 11

Fatigue

Question 12

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

Answer 12

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

Question 13

What will the nurse instruct an unregulated care provider (UCP) to do regarding the management of a patient’s pain?

Answer 13

“Let me know at least 30 minutes before you transport them so I can administer their analgesics.

Question 14

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

Answer 14

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

Question 15

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

Answer 15

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

Question 16

The nurse notices that their 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?

Answer 16

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

Question 17

The nurse is planning to measure a patient’s blood pressure. What does the systolic measurement represent?

Answer 17

The pressure exerted against the arterial wall, this is the first sound heard

Question 18

You have assigned a new unregulated care provider (UCP) to take routine vital signs. You notice that the UCP’s last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the UCP is obtaining falsely low blood pressure readings?

Answer 18

The blood pressure cuff is too wide for arm circumference.

Question 19

What should the nurse do if the patient’s blood pressure is not within normal limits?

Answer 19

Promptly report the assessment data to the nurse in charge or to the health care provider.

Question 20

What would the nurse do to prevent the spread of infection when assessing a patient’s blood pressure?

Answer 20

Clean the stethoscope with alcohol before and after using it.

Question 21

You have assigned a new unregulated care provider (UCP) to take routine vital signs. An experienced UCP has been asked to retake a blood pressure that the newly hired UCP has taken three times this week. As the nurse, what action do you take?

Answer 21

Observe the UCP as they obtain a blood pressure and pulse on a patient.

Question 22

The diastolic blood pressure measurement represents

Answer 22

the minimal pressure exerted against the arterial walls at all times.

Question 23

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

Answer 23

Blood pressure cuff is too loose around the arm.

Question 24

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

Answer 24

Patient has just finished having a cigarette. Smoking causes vasoconstriction, the narrowing of blood vessels.

Question 25

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?

Answer 25

Minimize the effect of anxiety.

Question 26

An older person recently on bed rest is assisted out of bed. The nurse measures their blood pressure as the patient changes position, and the results are as follows: 140/80 supine, 132/72 sitting, 108/60 standing. The patient also mentions that they feel light-headed. Which action should the nurse take first?

Answer 26

Assist the patient to return to a supine position.

Question 27

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

Answer 27

Use the right arm to take the blood pressure.

Question 28

Which action can the nurse take to keep a patient from consciously controlling their breathing during an assessment?

Answer 28

Assess respiration after measuring the pulse.

Question 29

On the last assessment of a patient’s respiration, their respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?

Answer 29

Count breaths for 60 seconds.

Question 30

When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?

Answer 30

The number of inspirations and expirations per minute

Question 31

During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?

Answer 31

Continue to count the patient’s breaths for a full 60 seconds.

Question 32

The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?

Answer 32

Encourage the patient to rest for 10 minutes before assessing respiration

Question 33

What will the nurse instruct an unregulated care provider (UCP) to do when measuring a patient’s rectal temperature using an electronic thermometer?

Answer 33

Use the probe with the red tip

Question 34

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

Answer 34

Patient has painful and swollen hemorrhoids.

Question 35

Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 38.6°C?

Answer 35

Assess oral temperature 30 minutes after the agent is administered.

Question 36

Which instruction might the nurse give to an unregulated care provider (UCP) that is applicable only to tympanic temperature assessment?

Answer 36

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

Question 37

Which instruction might the nurse give to an unregulated care provider (UCP) that is applicable only to temporal artery temperature assessment?

Answer 37

Place the sensor flush on the patient’s forehead.

Question 38

Which action would the nurse perform first when preparing to apply sterile gloves?

Answer 38

Assess the glove packaging for wetness or tears.

Question 39

When are sterile nonlatex gloves recommended for a sterile procedure?

Answer 39

When there is a possible sensitivity issue

Question 40

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands?

Answer 40

Selecting the proper glove size

Question 41

After applying sterile gloves, the patient states they are uncomfortable and would like to move to their left side. What is the best way for the nurse to keep the gloves sterile while waiting for an unregulated care provider (UCP) to position the patient for a sterile dressing change

Answer 41

Interlocking the fingers and keeping the hands above waist level

Question 42

Which protocol does not vary among institutions?

Answer 42

Use of sterile gloves for sterile procedures

Question 43

Skin inspection and palpation includes assessment for

Answer 43

All of these choices.

Question 44

An ABNORMAL angle between the nail base and the nail is called clubbing and may indicate which of the following conditions?

Answer 44

Cardiopulmonary disorder

Question 45

Which are the best places to check the skin for tenting, which is a sign of dehydration?

Answer 45

Forearm and sternum

Question 46

Which of the following is considered an abnormal finding in an older person?

Answer 46

Malignant melanoma

Question 47

The ABCDE rule of melanoma includes

Answer 47

asymmetry and evolvement of shape. border irregularity and colour variation. diameter larger than the eraser of a pencil. All of these choices. Asymmetry of shape is the A of the ABCDE rule of melanoma. Evolution of the mole pertains to the change and growth, which is the E of the ABCDE rule of melanoma. Border irregularity is the B and colour variation is the C of the ABCDE rule of melanoma. Diameter larger than the eraser of a pencil is the D of the ABCDE rule of melanoma.

Question 48

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

Answer 48

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

Question 49

What will the nurse instruct an unregulated care provider (UCP) to do when measuring an adult patient’s radial pulse?

Answer 49

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

Question 50

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

Answer 50

Assess the patient for a pulse deficit. Correct

Question 51

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

Answer 51

The heart rate will increase to circulate more available oxygen to tissues. Tachycardia is more than 100 beats/minute. tachycardica

Question 52

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

Answer 52

Measuring the patient’s radial pulse before and after exercise