Question 1

Before completing a blood pressure on an adult, which should the nurse do next after introducing self?

Accepted Answer

A) Provide privacy. 
B) Perform handwashing. 
C) Identify the client with two identifiers. 
D) Explain what he or she will be doing with the client. 
A) Provide privacy. 
B) Perform handwashing. 
C) Identify the client with two identifiers. 
D) Explain what he or she will be doing with the client.

Question 2

Which does the nurse observe for an adult client who has a negative Babinski response?

Accepted Answer

A) All toes turn inward. 
B) All toes curve upward. 
C) All toes spread outward. 
D) All toes bend downward. 
A) All toes turn inward. 
B) All toes curve upward. 
C) All toes spread outward. 
D) All toes bend downward.

Question 3

Based on the information provided, which client should the nurse see first?

Accepted Answer

A) Infant respirations 38/min 
B) 2-year-old pulse 112/min 
C) 6-year-old axillary temperature 97.5°F 
D) 10-year-old blood pressure 138/88 
A) Infant respirations 38/min 
B) 2-year-old pulse 112/min 
C) 6-year-old axillary temperature 97.5°F 
D) 10-year-old blood pressure 138/88

Question 4

The UAP notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and BP 98/72. Which is the best action the nurse should do next?

Accepted Answer

A) Ask the UAP to reassess the client. 
B) Inform the UAP to document these vital signs. 
C) Reassess the client to validate these vital signs. 
D) Notify the healthcare provider of these vital signs. 
A) Ask the UAP to reassess the client. 
B) Inform the UAP to document these vital signs. 
C) Reassess the client to validate these vital signs. 
D) Notify the healthcare provider of these vital signs.

Exam 52: Assessment

Before completing a blood pressure on an adult, which should the nurse do next after introducing self?

Which does the nurse observe for an adult client who has a negative Babinski response?

Based on the information provided, which client should the nurse see first?

The UAP notifies the nurse of these vital signs for a client on the medical-surgical unit: temperature 97.6°F, respirations 22, pulse 122, and BP 98/72. Which is the best action the nurse should do next?

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