Question 1

Which client could safely have a temperature taken via the oral route?

Accepted Answer

A) A client who is confused and disoriented secondary to a diagnosis of Alzheimer disease 
B) A client who had maxillofacial surgery 
C) An adult client with an elevated temperature of 102.4°F 
D) A client with a diagnosis of Bell palsy 
A) A client who is confused and disoriented secondary to a diagnosis of Alzheimer disease 
B) A client who had maxillofacial surgery 
C) An adult client with an elevated temperature of 102.4°F 
D) A client with a diagnosis of Bell palsy C

Question 2

When observing the unlicensed assistive personnel (UAP)checking pedal pulses,the nurse identifies which technique as appropriate?

Accepted Answer

A) Palpating the inner aspect of the biceps muscle of the arm 
B) Palpating the femoral artery as it passes alongside the inguinal ligament 
C) Palpating the pulse from the middle of the ankle to the space between the big and second toe 
D) Palpating the client's chest 
A) Palpating the inner aspect of the biceps muscle of the arm 
B) Palpating the femoral artery as it passes alongside the inguinal ligament 
C) Palpating the pulse from the middle of the ankle to the space between the big and second toe 
D) Palpating the client's chest C

Question 3

What is a normal oxygen saturation reading?

Accepted Answer

95% to 100%
Rationale: Normal oxygen saturation readings range between 95% and 100%.An oxygen saturation reading less than 70% could be life-threatening.Global Rationale: Normal oxygen saturation readings range between 95% and 100%.An oxygen saturation reading less than 70% could be life-threatening.

Question 4

The nurse working in the delivery room assesses a newborn infant delivered vaginally.The infant has a strong cry,is moving all extremities vigorously,and its color is pink.Which action by the nurse is the priority?

Accepted Answer

A) Stimulate the infant. 
B) Encourage infant-maternal bonding. 
C) Dry the infant. 
D) Administer oxygen. 
A) Stimulate the infant. 
B) Encourage infant-maternal bonding. 
C) Dry the infant. 
D) Administer oxygen.

Question 5

The nurse is able to demonstrate proper placement of the stethoscope when assessing the apical pulse by placing the bell at which location?

Accepted Answer

A) The brachial site 
B) The apex of the heart 
C) The carotid site 
D) The radial site 
A) The brachial site 
B) The apex of the heart 
C) The carotid site 
D) The radial site

Question 6

The nurse admits a client with a medical diagnosis of peripheral artery disease complaining of severe pain in the right leg.Which is the nurse's priority assessment?

Accepted Answer

A) Assessing the client's femoral pulses bilaterally 
B) Obtaining a thorough nursing history 
C) Assessing the client's radial and brachial pulses bilaterally 
D) Assessing the femoral,popliteal,posterior tibial,and pedal pulses bilaterally 
A) Assessing the client's femoral pulses bilaterally 
B) Obtaining a thorough nursing history 
C) Assessing the client's radial and brachial pulses bilaterally 
D) Assessing the femoral,popliteal,posterior tibial,and pedal pulses bilaterally

Question 7

What is a normal respiratory range for an adult?
____ to ____ breaths per minute

Accepted Answer

12-20
Rationale: 12-20 breaths

Question 8

Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?

Accepted Answer

A) An obese young adult client admitted for a fractured femur requiring traction 
B) A middle-aged adult client with hypertension admitted for removal of a tumor that might be cancerous 
C) A febrile elderly client with diabetes admitted for treatment of cellulitis 
D) An adolescent client admitted with an anxiety disorder 
A) An obese young adult client admitted for a fractured femur requiring traction 
B) A middle-aged adult client with hypertension admitted for removal of a tumor that might be cancerous 
C) A febrile elderly client with diabetes admitted for treatment of cellulitis 
D) An adolescent client admitted with an anxiety disorder

Question 9

The nurse is caring for a client diagnosed with cardiogenic shock who requires continuous oxygen saturation monitoring.Where would the nurse place the probe?

Accepted Answer

A) The fingers 
B) The toes 
C) The ear 
D) The thumb 
A) The fingers 
B) The toes 
C) The ear 
D) The thumb

Question 10

The nurse delegates the measurement of vital signs on three clients to the unlicensed assistive personnel (UAP).The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed.Which is the priority action by the nurse?

Accepted Answer

A) Commend the UAP for following the proper procedure. 
B) Inform the charge nurse that the UAP does not know how to measure blood pressures. 
C) Yell at the UAP and tell her she is incompetent. 
D) Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart,and demonstrate correct technique. 
A) Commend the UAP for following the proper procedure. 
B) Inform the charge nurse that the UAP does not know how to measure blood pressures. 
C) Yell at the UAP and tell her she is incompetent. 
D) Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart,and demonstrate correct technique.

Question 11

Which factors could influence oral temperature measurement?

Accepted Answer

A) Smoking 
B) Eating or drinking 
C) Exercise 
D) Perfusion 
E) Time of day 
A) Smoking 
B) Eating or drinking 
C) Exercise 
D) Perfusion 
E) Time of day

Question 12

Where would the nurse measure temperature if the client was confused and disoriented following rectal surgery?

Accepted Answer

A) Rectally 
B) Orally 
C) Axillary 
D) Either orally or tympanically 
A) Rectally 
B) Orally 
C) Axillary 
D) Either orally or tympanically

Question 13

The nurse working in an outpatient clinic provides care for a client who arrives a few minutes late for an appointment.The client is diaphoretic with a respiratory rate of 24 breaths per minute.Which is the priority action by the nurse?

Accepted Answer

A) Call the health care provider STAT to examine the client. 
B) Apply oxygen and sit the client up. 
C) Assess the client. 
D) Document the client's status,and place the chart so that the primary care provider is aware the client is ready to be seen. 
A) Call the health care provider STAT to examine the client. 
B) Apply oxygen and sit the client up. 
C) Assess the client. 
D) Document the client's status,and place the chart so that the primary care provider is aware the client is ready to be seen.

Question 14

Which term is used to describe the first sound heard by the nurse when measuring the client's blood pressure?

Accepted Answer

A) Diastolic 
B) Systolic 
C) Korotkoff's sound phase 4 
D) Korotkoff's sound phase 5 
A) Diastolic 
B) Systolic 
C) Korotkoff's sound phase 4 
D) Korotkoff's sound phase 5

Question 15

Which adult vital signs would the nurse need to report immediately?

Accepted Answer

A) 99.2°F;100;20;138/88 
B) 100.2°F;88;18;128/72 
C) 97.4°F;96;28;142/82 
D) 98°F;64;14;88/60 
A) 99.2°F;100;20;138/88 
B) 100.2°F;88;18;128/72 
C) 97.4°F;96;28;142/82 
D) 98°F;64;14;88/60

Question 16

The nurse working night shift recognizes the value of allowing clients to sleep uninterrupted whenever possible.Which client would the nurse wake to assess vital signs?

Accepted Answer

A) Postoperative client who had surgery 5 days ago and will be discharged in the morning 
B) Client who has been afebrile for 3 days on antibiotics 
C) Client who required medication earlier in the day for chest pain 
D) A client who required the insertion of an indwelling catheter this evening secondary to urine retention related to an enlarged prostate 
A) Postoperative client who had surgery 5 days ago and will be discharged in the morning 
B) Client who has been afebrile for 3 days on antibiotics 
C) Client who required medication earlier in the day for chest pain 
D) A client who required the insertion of an indwelling catheter this evening secondary to urine retention related to an enlarged prostate

Question 17

Which factors could influence blood pressure measurement?

Accepted Answer

A) Age 
B) Height 
C) Sex 
D) Race 
E) Obesity 
A) Age 
B) Height 
C) Sex 
D) Race 
E) Obesity

Question 18

The nurse is caring for several clients.Rank the order in which the nurse would assess vital signs for these clients.

Accepted Answer

A) Client who is returning from the operating room after abdominal surgery Response 
B) Client who will walk the hallway for the first time Response 
C) Client who was febrile and required an antipyretic medication 1 hour ago Response 
D) Client who is to be discharged this morning 
A) Client who is returning from the operating room after abdominal surgery Response 
B) Client who will walk the hallway for the first time Response 
C) Client who was febrile and required an antipyretic medication 1 hour ago Response 
D) Client who is to be discharged this morning

Question 19

The nurse is reviewing a client's vital signs from birth to age 10.Which changes would the nurse expect to find?

Accepted Answer

A) Reduction in temperature,increase in heart rate,decrease in respiratory rate,and increase in blood pressure 
B) Reduction in oxygen saturation,decreased heart and respiratory rate,and decreased blood pressure 
C) Reduced heart and respiratory rate and increased blood pressure 
D) Decreased temperature,reduced heart and respiratory rate,and increased blood pressure 
A) Reduction in temperature,increase in heart rate,decrease in respiratory rate,and increase in blood pressure 
B) Reduction in oxygen saturation,decreased heart and respiratory rate,and decreased blood pressure 
C) Reduced heart and respiratory rate and increased blood pressure 
D) Decreased temperature,reduced heart and respiratory rate,and increased blood pressure

Question 20

In order to get an accurate reading,which technique would the nurse use to measure the client's respirations?

Accepted Answer

A) Stare intently at the client's chest. 
B) Place a hand on the client's chest to feel the thoracic cavity move. 
C) Maintain the fingers on the radial pulse. 
D) Watch the nose flare with each respiration. 
A) Stare intently at the client's chest. 
B) Place a hand on the client's chest to feel the thoracic cavity move. 
C) Maintain the fingers on the radial pulse. 
D) Watch the nose flare with each respiration.

Exam 2: Vital Signs

Which client could safely have a temperature taken via the oral route?

When observing the unlicensed assistive personnel (UAP)checking pedal pulses,the nurse identifies which technique as appropriate?

What is a normal oxygen saturation reading?

The nurse working in the delivery room assesses a newborn infant delivered vaginally.The infant has a strong cry,is moving all extremities vigorously,and its color is pink.Which action by the nurse is the priority?

The nurse is able to demonstrate proper placement of the stethoscope when assessing the apical pulse by placing the bell at which location?

The nurse admits a client with a medical diagnosis of peripheral artery disease complaining of severe pain in the right leg.Which is the nurse's priority assessment?

What is a normal respiratory range for an adult? ____ to ____ breaths per minute

Which client would the nurse anticipate to most likely have a higher-than-normal pulse rate?

The nurse is caring for a client diagnosed with cardiogenic shock who requires continuous oxygen saturation monitoring.Where would the nurse place the probe?

Which factors could influence oral temperature measurement?

Where would the nurse measure temperature if the client was confused and disoriented following rectal surgery?

The nurse working in an outpatient clinic provides care for a client who arrives a few minutes late for an appointment.The client is diaphoretic with a respiratory rate of 24 breaths per minute.Which is the priority action by the nurse?

Which term is used to describe the first sound heard by the nurse when measuring the client's blood pressure?

Which adult vital signs would the nurse need to report immediately?

The nurse working night shift recognizes the value of allowing clients to sleep uninterrupted whenever possible.Which client would the nurse wake to assess vital signs?

Which factors could influence blood pressure measurement?

The nurse is caring for several clients.Rank the order in which the nurse would assess vital signs for these clients.

The nurse is reviewing a client's vital signs from birth to age 10.Which changes would the nurse expect to find?

In order to get an accurate reading,which technique would the nurse use to measure the client's respirations?

Foundational Skills

Health Assessment

Diagnostic Testing

Client Hygiene

Bed-Making

Infection Control

Heat and Cold Therapy

Pain Management

Positioning the Client

Mobilizing the Client

Fall Prevention and Restraints

Maintaining Joint Mobility

Drug Calculations

Administering Oral and Enteral Medications

Administering Topical Medications

Administering Parenteral Medications

Administering Intravenous Therapy

Feeding Clients

Assisting With Urinary Elimination

Assisting With Fecal Elimination

Caring for Clients With Peritoneal Dialysis

Promoting Circulation

Breathing Exercises

Oxygen Therapy

Suctioning

Caring for the Client With a Tracheostomy

Assisting With Mechanical Ventilation

Caring for the Client With Chest Tube Drainage

Administering Emergency Measures to the Hospitalized Client

Performing Wound and Pressure Ulcer Care

Orthopedic Care

Performing Perioperative Care

End-Of-Life Care

Filters

What is a normal respiratory range for an adult? to breaths per minute