Question 1

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

Accepted Answer

A)  a breathing pattern of dyspnea followed by a short period of apnea. 
B)  rapid wheezing respirations for two or three breaths with short periods of apnea. 
C)  quick shallow respirations with long periods of apnea. 
D)  respirations gradually decreasing in rate and depth. 
A)  a breathing pattern of dyspnea followed by a short period of apnea. 
B)  rapid wheezing respirations for two or three breaths with short periods of apnea. 
C)  quick shallow respirations with long periods of apnea. 
D)  respirations gradually decreasing in rate and depth.

Question 2

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

Accepted Answer

A)  14 mm Hg. 
B)  54 mm Hg. 
C)  64 mm Hg. 
D)  80 mm Hg. 
A)  14 mm Hg. 
B)  54 mm Hg. 
C)  64 mm Hg. 
D)  80 mm Hg.

Question 3

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

Accepted Answer

A)  keep the patient in bed in a high Fowler's position. 
B)  allow the patient to sit on the side of the bed for a minute before standing. 
C)  instruct the patient to use the wheelchair for all mobility activity. 
D)  help the patient to rise quickly and support the patient for a minute. 
A)  keep the patient in bed in a high Fowler's position. 
B)  allow the patient to sit on the side of the bed for a minute before standing. 
C)  instruct the patient to use the wheelchair for all mobility activity. 
D)  help the patient to rise quickly and support the patient for a minute.

Question 4

To ensure an accurate reading when using a glass oral thermometer, it is necessary to:

Accepted Answer

A)  rinse the thermometer with water. 
B)  wipe the thermometer with alcohol. 
C)  shake down the galinstan alloy to below normal. 
D)  dry the thermometer with a dry cotton ball. 
A)  rinse the thermometer with water. 
B)  wipe the thermometer with alcohol. 
C)  shake down the galinstan alloy to below normal. 
D)  dry the thermometer with a dry cotton ball.

Question 5

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply.)

Accepted Answer

A)  previous mastectomy. 
B)  patent IV line. 
C)  injured hand. 
D)  2-year-old hand amputation. 
E)  dialysis shunt. 
A)  previous mastectomy. 
B)  patent IV line. 
C)  injured hand. 
D)  2-year-old hand amputation. 
E)  dialysis shunt.

Question 6

The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:

Accepted Answer

A)  a blood pressure elevation. 
B)  a temperature abnormality. 
C)  a decrease in pulse rate. 
D)  depressed respirations. 
A)  a blood pressure elevation. 
B)  a temperature abnormality. 
C)  a decrease in pulse rate. 
D)  depressed respirations.

Question 7

The nurse taking an apical pulse would place the stethoscope at:

Accepted Answer

A)  the left of the sternum at the third intercostal space. 
B)  directly below the sternum. 
C)  slightly above the left nipple. 
D)  the left midclavicular line at the fifth intercostal space. 
A)  the left of the sternum at the third intercostal space. 
B)  directly below the sternum. 
C)  slightly above the left nipple. 
D)  the left midclavicular line at the fifth intercostal space.

Question 8

For the nurse to assess the most accurate respiration count, the nurse should:

Accepted Answer

A)  inform the patient about his respirations and ask him to breathe normally. 
B)  count each inhalation and expiration for 1 full minute. 
C)  watch the patient's chest rise and fall from a distance. 
D)  continue to hold the patient's radial pulse, and count the respirations for 30 seconds and multiply them by 2. 
A)  inform the patient about his respirations and ask him to breathe normally. 
B)  count each inhalation and expiration for 1 full minute. 
C)  watch the patient's chest rise and fall from a distance. 
D)  continue to hold the patient's radial pulse, and count the respirations for 30 seconds and multiply them by 2.

Question 9

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

Accepted Answer

A)  increase in temperature. 
B)  decrease in blood pressure. 
C)  decrease in pulse. 
D)  decrease in respirations. 
A)  increase in temperature. 
B)  decrease in blood pressure. 
C)  decrease in pulse. 
D)  decrease in respirations.

Question 10

When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:

Accepted Answer

A)  pleased that the temperature has come up to normal. 
B)  satisfied that the patient is warm enough. 
C)  concerned about the evidence of fever. 
D)  relieved that the patient is improving. 
A)  pleased that the temperature has come up to normal. 
B)  satisfied that the patient is warm enough. 
C)  concerned about the evidence of fever. 
D)  relieved that the patient is improving.

Question 11

A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be:

Accepted Answer

A)  rectal. 
B)  tympanic arterial thermometer. 
C)  axillary. 
D)  tympanic. 
A)  rectal. 
B)  tympanic arterial thermometer. 
C)  axillary. 
D)  tympanic.

Question 12

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

Accepted Answer

A)  being transferred to ice packs. 
B)  production of sweat. 
C)  being removed by fast air currents from a fan. 
D)  exposure to a cool environment. 
A)  being transferred to ice packs. 
B)  production of sweat. 
C)  being removed by fast air currents from a fan. 
D)  exposure to a cool environment.

Question 13

The nurse would document a patient as being febrile if the patient's temperature was over:

Accepted Answer

A)  99.5° F 
B)  99.8° F 
C)  100° F 
D)  100.5° F 
A)  99.5° F 
B)  99.8° F 
C)  100° F 
D)  100.5° F

Exam 21: Measuring Vital Signs

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

To ensure an accurate reading when using a glass oral thermometer, it is necessary to:

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply.)

The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:

The nurse taking an apical pulse would place the stethoscope at:

For the nurse to assess the most accurate respiration count, the nurse should:

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:

A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be:

The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by:

The nurse would document a patient as being febrile if the patient's temperature was over:

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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