Question 1

Which factors could influence pulse measurement?

Accepted Answer

A) Activity 
B) Temperature 
C) Stress 
D) Antibiotic medications 
E) Hydration 
A) Activity 
B) Temperature 
C) Stress 
D) Antibiotic medications 
E) Hydration

Question 2

The nurse is caring for a client who had bilateral mastectomies.Where would the nurse measure the client's blood pressure to obtain the most accurate reading?

Accepted Answer

A) Either upper arm using the brachial artery 
B) Either forearm using the radial artery 
C) In the lower leg using the posterior tibial artery 
D) In the thigh using the popliteal artery 
A) Either upper arm using the brachial artery 
B) Either forearm using the radial artery 
C) In the lower leg using the posterior tibial artery 
D) In the thigh using the popliteal artery

Question 3

The nurse is caring for a homeless client brought to the emergency department with possible hypothermia.The nurse places the pulse oximeter probe on the client's finger and gets a reading of 38%.The client's respiratory rate is 22 breaths per minute,breath sounds are clear and equal,color is pale pink,and the client denies any history of respiratory distress.Which is the priority action by the nurse?

Accepted Answer

A) Apply oxygen 
B) Call the health care provider 
C) Call the rapid response team 
D) Move the pulse oximetry sensor to the ear or nose 
A) Apply oxygen 
B) Call the health care provider 
C) Call the rapid response team 
D) Move the pulse oximetry sensor to the ear or nose

Question 4

The nurse is caring for a client with vital signs 97.2°F;112;48;104/86;and oxygen saturation is 76%.Place the nursing actions in order of their priority for this client.

Accepted Answer

A) Assess the client.Response 
B) Reduce client anxiety.Response 
C) Notify the health care provider.Response 
D) Obtain assistance from another nurse or member of the team.Response 
E) Administer oxygen. 
A) Assess the client.Response 
B) Reduce client anxiety.Response 
C) Notify the health care provider.Response 
D) Obtain assistance from another nurse or member of the team.Response 
E) Administer oxygen.

Question 5

The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with the chest and abdomen alternately rising,blue discoloration of the fingertips,and noisy difficult respirations.How would the nurse describe the client's condition when calling the health care provider?

Accepted Answer

A) Client is tachypneic with costal breathing and cyanosis. 
B) Client is bradycardic with diaphragmatic breathing and cyanosis. 
C) Client is demonstrating diaphragmatic breathing,and is dyspneic and cyanotic. 
D) Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds. 
A) Client is tachypneic with costal breathing and cyanosis. 
B) Client is bradycardic with diaphragmatic breathing and cyanosis. 
C) Client is demonstrating diaphragmatic breathing,and is dyspneic and cyanotic. 
D) Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.

Question 6

The nurse is preparing to assess vital signs for clients currently assigned.For which client would measuring temperature via the rectal route be contraindicated?

Accepted Answer

A) A comatose client with an oral endotracheal tube in place 
B) An adolescent client who has had recent maxillofacial surgery 
C) A toddler with previous temperature reading of 104.2°F axillary 
D) A client with a fever who is in a chronic vegetative state 
A) A comatose client with an oral endotracheal tube in place 
B) An adolescent client who has had recent maxillofacial surgery 
C) A toddler with previous temperature reading of 104.2°F axillary 
D) A client with a fever who is in a chronic vegetative state

Question 7

The nurse is caring for a client requiring continuous pulse oximetry readings.How often would the nurse alter the probe site?

Accepted Answer

A) Every 2 hours 
B) Every 4 hours if the probe is an adhesive wraparound sensor 
C) Every 4 hours if the probe is a spring-loaded sensor 
D) Every 2 hours if the probe is an adhesive wraparound sensor 
A) Every 2 hours 
B) Every 4 hours if the probe is an adhesive wraparound sensor 
C) Every 4 hours if the probe is a spring-loaded sensor 
D) Every 2 hours if the probe is an adhesive wraparound sensor

Question 8

What is a normal oral temperature range for an adult client?
____ to ____°F

Accepted Answer

98^°F to 98.6^°F Rationale: The no

Question 9

The nurse is caring for a client with a history of arrhythmia resulting in an irregular pulse.How long would the nurse count the pulse to get the most accurate reading?

Accepted Answer

A) 15 seconds and multiply by 4 
B) 30 seconds and multiply by 2 
C) 1 minute 
D) 2 minutes 
A) 15 seconds and multiply by 4 
B) 30 seconds and multiply by 2 
C) 1 minute 
D) 2 minutes

Question 10

Which is the appropriate site to use when taking an infant's temperature?

Accepted Answer

A) Axillae 
B) Temporal artery 
C) Tympanic membrane 
D) Oral cavity 
A) Axillae 
B) Temporal artery 
C) Tympanic membrane 
D) Oral cavity

Question 11

The nurse is caring for a client with a fever of 101.8°F oral.Which other vital signs would the nurse anticipate would be affected?

Accepted Answer

A) Pulse rate 
B) Respiratory rate 
C) Diastolic blood pressure 
D) Systolic blood pressure 
E) Oxygen saturation 
A) Pulse rate 
B) Respiratory rate 
C) Diastolic blood pressure 
D) Systolic blood pressure 
E) Oxygen saturation

Question 12

Which factors could influence oxygen saturation measurement?

Accepted Answer

A) Hemoglobin 
B) Hematocrit 
C) Carbon dioxide poisoning 
D) Activity 
E) Circulation 
A) Hemoglobin 
B) Hematocrit 
C) Carbon dioxide poisoning 
D) Activity 
E) Circulation

Question 13

The nurse is measuring the client's radial pulse.How does the nurse properly perform this procedure?

Accepted Answer

A) Place two fingers on the medial side of the inner wrist gently on the surface of the skin. 
B) Place the thumb on the lateral side of the wrist and apply gentle pressure. 
C) Place two fingers on the lateral side of the inner wrist and apply gentle pressure. 
D) Place the thumb on the medial side of the wrist gently. 
A) Place two fingers on the medial side of the inner wrist gently on the surface of the skin. 
B) Place the thumb on the lateral side of the wrist and apply gentle pressure. 
C) Place two fingers on the lateral side of the inner wrist and apply gentle pressure. 
D) Place the thumb on the medial side of the wrist gently.

Question 14

What is a normal pulse range for an adult?
____ to ____ beats per minute

Accepted Answer

60-100
Rationale: Normal pulse range for

Question 15

Prior to assessing the adult client's temperature rectally,which action by the nurse is the most appropriate?

Accepted Answer

A) Lubricate the tip of the thermometer. 
B) Obtain a health care provider's order. 
C) Position the client in the Trendelenburg position. 
D) Position the client in the Fowler's position. 
A) Lubricate the tip of the thermometer. 
B) Obtain a health care provider's order. 
C) Position the client in the Trendelenburg position. 
D) Position the client in the Fowler's position.

Question 16

The nurse is caring for a client experiencing dyspnea.Which symptoms would the nurse anticipate this client to have?

Accepted Answer

A) Rapid respirations 
B) Reduced oxygen saturation 
C) Noisy breath sounds 
D) Deep breathing 
E) Shallow breathing 
A) Rapid respirations 
B) Reduced oxygen saturation 
C) Noisy breath sounds 
D) Deep breathing 
E) Shallow breathing

Question 17

When is it inappropriate to measure vital signs?

Accepted Answer

A) Before and after a procedure 
B) On admission to the hospital 
C) When client is in pain 
D) When the client is resting 
A) Before and after a procedure 
B) On admission to the hospital 
C) When client is in pain 
D) When the client is resting

Question 18

The nurse assesses vital signs on four clients.Which client would be the first priority for the nurse to assess based on the vital signs?

Accepted Answer

A) 98.6°F;88;16;134/88 
B) 98.2°F;60;12;92/64 
C) 100.8°F;102;18;136/84 
D) 98.7°F;96;14;156/102 
A) 98.6°F;88;16;134/88 
B) 98.2°F;60;12;92/64 
C) 100.8°F;102;18;136/84 
D) 98.7°F;96;14;156/102

Question 19

The nurse working in the emergency department admits a 2-month-old infant whose mother reports had a temperature of 104.2°F axillary.Which route would the nurse use to measure the infant's temperature?

Accepted Answer

A) Tympanically 
B) Orally 
C) Axillary 
D) Rectally 
A) Tympanically 
B) Orally 
C) Axillary 
D) Rectally

Question 20

The nurse is working at a local fair on a warm day in August.Which reading would concern the nurse the most?

Accepted Answer

A) 22-year-old man with temperature of 100.2°F oral 
B) 74-year-old woman with temperature of 100.8°F oral 
C) Newborn temperature of 99.6°F axillary 
D) Middle-aged adult with temperature of 99.2°F oral 
A) 22-year-old man with temperature of 100.2°F oral 
B) 74-year-old woman with temperature of 100.8°F oral 
C) Newborn temperature of 99.6°F axillary 
D) Middle-aged adult with temperature of 99.2°F oral

Exam 2: Vital Signs

Which factors could influence pulse measurement?

The nurse is caring for a client who had bilateral mastectomies.Where would the nurse measure the client's blood pressure to obtain the most accurate reading?

The nurse is caring for a client with vital signs 97.2°F;112;48;104/86;and oxygen saturation is 76%.Place the nursing actions in order of their priority for this client.

The nurse is preparing to assess vital signs for clients currently assigned.For which client would measuring temperature via the rectal route be contraindicated?

The nurse is caring for a client requiring continuous pulse oximetry readings.How often would the nurse alter the probe site?

What is a normal oral temperature range for an adult client? ____ to ____°F

The nurse is caring for a client with a history of arrhythmia resulting in an irregular pulse.How long would the nurse count the pulse to get the most accurate reading?

Which is the appropriate site to use when taking an infant's temperature?

The nurse is caring for a client with a fever of 101.8°F oral.Which other vital signs would the nurse anticipate would be affected?

Which factors could influence oxygen saturation measurement?

The nurse is measuring the client's radial pulse.How does the nurse properly perform this procedure?

What is a normal pulse range for an adult? ____ to ____ beats per minute

Prior to assessing the adult client's temperature rectally,which action by the nurse is the most appropriate?

The nurse is caring for a client experiencing dyspnea.Which symptoms would the nurse anticipate this client to have?

When is it inappropriate to measure vital signs?

The nurse assesses vital signs on four clients.Which client would be the first priority for the nurse to assess based on the vital signs?

The nurse working in the emergency department admits a 2-month-old infant whose mother reports had a temperature of 104.2°F axillary.Which route would the nurse use to measure the infant's temperature?

The nurse is working at a local fair on a warm day in August.Which reading would concern the nurse the most?

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

The nurse is caring for a client with vital signs 97.2^°F;112;48;104/86;and oxygen saturation is 76%.Place the nursing actions in order of their priority for this client.

What is a normal oral temperature range for an adult client? to ^°F

The nurse is caring for a client with a fever of 101.8^°F oral.Which other vital signs would the nurse anticipate would be affected?

What is a normal pulse range for an adult? to beats per minute

The nurse working in the emergency department admits a 2-month-old infant whose mother reports had a temperature of 104.2^°F axillary.Which route would the nurse use to measure the infant's temperature?