Question 1

An older adult patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

Accepted Answer

A)  Take the patient's vital signs every 4 hours, including temperature. 
B)  Provide fluids to increase circulation. 
C)  Increase room temperature to 72° F (22.2° 
C)  and add blankets to the bed. 
D)  Check the temperature orally to confirm the accuracy of the reading. 
A)  Take the patient's vital signs every 4 hours, including temperature. 
B)  Provide fluids to increase circulation. 
C)  Increase room temperature to 72° F (22.2° 
C)  and add blankets to the bed. 
D)  Check the temperature orally to confirm the accuracy of the reading. C

Question 2

The nurse would record a pulse as bradycardic if the rate were:

Accepted Answer

A)  64 beats/min. 
B)  62 beats/min. 
C)  60 beats/min. 
D)  59 beats/min. 
A)  64 beats/min. 
B)  62 beats/min. 
C)  60 beats/min. 
D)  59 beats/min. D

Question 3

The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:

Accepted Answer

A)  using a narrow cuff for an obese patient. 
B)  making sure the width of the bladder is at least 3 inches. 
C)  confirming that the bladder goes around three fourths of the arm. 
D)  always using a wide cuff. 
A)  using a narrow cuff for an obese patient. 
B)  making sure the width of the bladder is at least 3 inches. 
C)  confirming that the bladder goes around three fourths of the arm. 
D)  always using a wide cuff. C

Question 4

The nurse covers a newborn baby's head with a cap, because the head:

Accepted Answer

A)  is wet and needs to be dried. 
B)  has large fontanels. 
C)  allows loss of body heat. 
D)  can be reshaped more quickly. 
A)  is wet and needs to be dried. 
B)  has large fontanels. 
C)  allows loss of body heat. 
D)  can be reshaped more quickly.

Question 5

The nurse clarifies the average cardiac output in the adult is about _____ L/min.

Accepted Answer

5
The average cardia

Question 6

A nurse educates patients with prehypertension to implement lifestyle changes that would decrease their systolic pressure from 140 to 120 mm Hg. Which of the following is his or her rationale for this?

Accepted Answer

A)  Reduced deaths by 50% in people over age 40. 
B)  Reduced rates of strokes by 10%. 
C)  Reduced rates of COPD by 25%. 
D)  Reduced rates of heart attacks by 30%. 
A)  Reduced deaths by 50% in people over age 40. 
B)  Reduced rates of strokes by 10%. 
C)  Reduced rates of COPD by 25%. 
D)  Reduced rates of heart attacks by 30%.

Question 7

The accuracy in measuring the apical pulse is enhanced when the nurse:

Accepted Answer

A)  counts the radial pulse at the same time. 
B)  counts the beats for a minute. 
C)  keeps the patient warm. 
D)  uses the bell of the stethoscope. 
A)  counts the radial pulse at the same time. 
B)  counts the beats for a minute. 
C)  keeps the patient warm. 
D)  uses the bell of the stethoscope.

Question 8

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will:

Accepted Answer

A)  offer warm fluids to the patient, if permitted." 
B)  instruct the patient to remain on strict bed rest." 
C)  provide the patient with additional blankets." 
D)  encourage the patient to increase his muscle activity." 
A)  offer warm fluids to the patient, if permitted." 
B)  instruct the patient to remain on strict bed rest." 
C)  provide the patient with additional blankets." 
D)  encourage the patient to increase his muscle activity."

Question 9

The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:

Accepted Answer

A)  a temperature of 102° F. 
B)  respirations of 16 breaths/min. 
C)  a pulse rate of 120 beats/min. 
D)  blood pressure of 128/86 mm Hg. 
A)  a temperature of 102° F. 
B)  respirations of 16 breaths/min. 
C)  a pulse rate of 120 beats/min. 
D)  blood pressure of 128/86 mm Hg.

Question 10

The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:

Accepted Answer

A)  strength of the femoral pulse. 
B)  presence of the pedal pulse. 
C)  temperature of the right foot. 
D)  ability to move the left toes. 
A)  strength of the femoral pulse. 
B)  presence of the pedal pulse. 
C)  temperature of the right foot. 
D)  ability to move the left toes.

Question 11

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Accepted Answer

A)  continue to listen until the cuff is deflated. 
B)  pump up the cuff until no sound is heard and then let the air out. 
C)  make sure the bell of the stethoscope is placed firmly over the artery. 
D)  stop midway and begin to inflate again. 
A)  continue to listen until the cuff is deflated. 
B)  pump up the cuff until no sound is heard and then let the air out. 
C)  make sure the bell of the stethoscope is placed firmly over the artery. 
D)  stop midway and begin to inflate again.

Question 12

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

Accepted Answer

A)  clear tapping that gradually grows louder. 
B)  murmur or swishing sound that increases with depression of the cuff. 
C)  sudden change or muffling of the sound. 
D)  louder knocking sound that occurs with each heartbeat. 
A)  clear tapping that gradually grows louder. 
B)  murmur or swishing sound that increases with depression of the cuff. 
C)  sudden change or muffling of the sound. 
D)  louder knocking sound that occurs with each heartbeat.

Question 13

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

Accepted Answer

A)  5-year-old with a facial laceration. 
B)  12-year-old patient with a recent seizure. 
C)  15-year-old with an abscessed tooth. 
D)  20-year-old with severe dehydration. 
A)  5-year-old with a facial laceration. 
B)  12-year-old patient with a recent seizure. 
C)  15-year-old with an abscessed tooth. 
D)  20-year-old with severe dehydration.

Question 14

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Accepted Answer

A)  notify the charge nurse of the hypotension. 
B)  notify the doctor of the bradycardia. 
C)  check medications that might be the cause of the irregularity. 
D)  check the patient's record to determine his baseline blood pressure. 
A)  notify the charge nurse of the hypotension. 
B)  notify the doctor of the bradycardia. 
C)  check medications that might be the cause of the irregularity. 
D)  check the patient's record to determine his baseline blood pressure.

Question 15

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Accepted Answer

A)  assessing the amount of blood passing through the sensor. 
B)  assessing the relative warmth of the skin on the monitored part. 
C)  measuring the oxygenated hemoglobin through a capillary bed. 
D)  measuring the respirations to the blood pressure via infrared rays. 
A)  assessing the amount of blood passing through the sensor. 
B)  assessing the relative warmth of the skin on the monitored part. 
C)  measuring the oxygenated hemoglobin through a capillary bed. 
D)  measuring the respirations to the blood pressure via infrared rays.

Question 16

The nurse converts the Fahrenheit temperature of 99.2 to a Celsius reading of _____________________.

Accepted Answer

37.3
To convert Fahrenheit to

Question 17

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

Accepted Answer

A)  location. 
B)  duration. 
C)  usual methods of relief. 
D)  character. 
E)  intensity. 
A)  location. 
B)  duration. 
C)  usual methods of relief. 
D)  character. 
E)  intensity.

Question 18

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

Accepted Answer

A)  stronger. 
B)  weaker. 
C)  bradycardic. 
D)  irregular. 
A)  stronger. 
B)  weaker. 
C)  bradycardic. 
D)  irregular.

Question 19

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

Accepted Answer

A)  listens to the apical pulse for 1 full minute. 
B)  takes the pulse for 30 seconds on the other wrist. 
C)  records the findings on the graphic sheet. 
D)  takes the pulse for 1 full minute on the other wrist. 
A)  listens to the apical pulse for 1 full minute. 
B)  takes the pulse for 30 seconds on the other wrist. 
C)  records the findings on the graphic sheet. 
D)  takes the pulse for 1 full minute on the other wrist.

Question 20

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Accepted Answer

A)  dizziness upon rising to a standing position. 
B)  a drop of 15 to 20 mm Hg from baseline when changing position. 
C)  nausea. 
D)  syncope. 
E)  blurred vision. 
A)  dizziness upon rising to a standing position. 
B)  a drop of 15 to 20 mm Hg from baseline when changing position. 
C)  nausea. 
D)  syncope. 
E)  blurred vision.

Exam 21: Measuring Vital Signs

An older adult patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient's need?

The nurse would record a pulse as bradycardic if the rate were:

The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:

The nurse covers a newborn baby's head with a cap, because the head:

The nurse clarifies the average cardiac output in the adult is about _____ L/min.

A nurse educates patients with prehypertension to implement lifestyle changes that would decrease their systolic pressure from 140 to 120 mm Hg. Which of the following is his or her rationale for this?

The accuracy in measuring the apical pulse is enhanced when the nurse:

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will:

The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:

The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

The nurse converts the Fahrenheit temperature of 99.2 to a Celsius reading of _____________________.

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

The Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse Patient Relationship

Patient Education and Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, and End-of-Life Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Safe Lifting, Moving, and Positioning of Patients

Assisting with Hygiene Personal Care Skin Care and the Prevention of Pressure Ulcers

Patient Environment and Safety

Assessing Health Status

Admitting Transferring and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid-Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Nutritional Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain Comfort and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Older Adult

Common Psychosocial Care Problems of Older Adults

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