Question 1

The nurse is going to measure the patient's pulse oxygen saturation.She knows pulse oximetry readings can be influenced by several factors.(Select all that apply.)

Accepted Answer

A)  Nail polish 
B)  Respiratory treatments 
C)  Poor circulation to the site 
D)  Tremors 
E)  Hemoglobin levels
F) None of the above 
A)  Nail polish 
B)  Respiratory treatments 
C)  Poor circulation to the site 
D)  Tremors 
E)  Hemoglobin levels
F) None of the above

Question 2

The nurse is caring for a lethargic,18-year-old patient with a respiratory rate of 32 breaths per minute.What is the first action the nurse should take?

Accepted Answer

A)  Place the patient in high-Fowler's position. 
B)  Assess the remaining vital signs. 
C)  Reassess the respiratory rate. 
D)  Notify the healthcare provider. 
A)  Place the patient in high-Fowler's position. 
B)  Assess the remaining vital signs. 
C)  Reassess the respiratory rate. 
D)  Notify the healthcare provider.

Question 3

A patient has been experiencing some circulatory issues,and an apical-radial pulse is ordered.Nursing care is correct if which procedure is followed?

Accepted Answer

A)  One nurse counts the apical pulse at the same time another nurse counts the radial pulse. 
B)  The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive personnel (NAP) with 10 years' experience. 
C)  The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds. 
D)  The apical pulse is counted for 30 seconds, the radial pulse for 30 seconds, and the results are doubled. 
A)  One nurse counts the apical pulse at the same time another nurse counts the radial pulse. 
B)  The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive personnel (NAP) with 10 years' experience. 
C)  The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds. 
D)  The apical pulse is counted for 30 seconds, the radial pulse for 30 seconds, and the results are doubled.

Question 4

At what distance above the antecubital fossa does the nurse position a blood pressure (BP)cuff when using the brachial artery to measure BP?

Accepted Answer

A)  2.5 cm (1 inch) 
B)  0.6 cm (1/4 inch) 
C)  1.3 cm (1/2 inch) 
D)  5.1 cm (2 inches) 
A)  2.5 cm (1 inch) 
B)  0.6 cm (1/4 inch) 
C)  1.3 cm (1/2 inch) 
D)  5.1 cm (2 inches)

Question 5

The nurse is running a blood pressure screening clinic at the community health center.Which action should the nurse implement to obtain an accurate measurement of a patient's blood pressure on an upper extremity?

Accepted Answer

A)  Use a cuff with a cuff width that is 40% wider than the circumference of the arm. 
B)  Limit the cuff deflation rate to 10 mm Hg per second or heartbeat. 
C)  Record the second Korotkoff sound as the systolic pressure. 
D)  Apply the diaphragm of the stethoscope lightly over the brachial artery. 
A)  Use a cuff with a cuff width that is 40% wider than the circumference of the arm. 
B)  Limit the cuff deflation rate to 10 mm Hg per second or heartbeat. 
C)  Record the second Korotkoff sound as the systolic pressure. 
D)  Apply the diaphragm of the stethoscope lightly over the brachial artery.

Question 6

You have delegated the task of obtaining a pulse oximetry reading to the NAP.Which of the following statements by the NAP indicates a need for further education?

Accepted Answer

A)  "The pulse oximetry reading was 95%." 
B)  "The patient's pulse rate was 78 according to the readout." 
C)  "I made sure the patient did not have nail polish on." 
D)  "I made sure the patient was not receiving a respiratory treatment." 
A)  "The pulse oximetry reading was 95%." 
B)  "The patient's pulse rate was 78 according to the readout." 
C)  "I made sure the patient did not have nail polish on." 
D)  "I made sure the patient was not receiving a respiratory treatment."

Question 7

The nurse delegates temperature measurement to nursing assistive personnel (NAP).For which patient should the nurse instruct the NAP to use the tympanic thermometer?

Accepted Answer

A)  10-year-old patient with a left leg fracture 
B)  12-hour-old infant in the newborn nursery 
C)  5-year-old patient with bilateral otitis media 
D)  15-year-old patient with postbilateral tympanoplasties 
A)  10-year-old patient with a left leg fracture 
B)  12-hour-old infant in the newborn nursery 
C)  5-year-old patient with bilateral otitis media 
D)  15-year-old patient with postbilateral tympanoplasties

The nurse is going to measure the patient's pulse oxygen saturation.She knows pulse oximetry readings can be influenced by several factors.(Select all that apply.)

The nurse is caring for a lethargic,18-year-old patient with a respiratory rate of 32 breaths per minute.What is the first action the nurse should take?

A patient has been experiencing some circulatory issues,and an apical-radial pulse is ordered.Nursing care is correct if which procedure is followed?

At what distance above the antecubital fossa does the nurse position a blood pressure (BP)cuff when using the brachial artery to measure BP?

The nurse is running a blood pressure screening clinic at the community health center.Which action should the nurse implement to obtain an accurate measurement of a patient's blood pressure on an upper extremity?

You have delegated the task of obtaining a pulse oximetry reading to the NAP.Which of the following statements by the NAP indicates a need for further education?

The nurse delegates temperature measurement to nursing assistive personnel (NAP).For which patient should the nurse instruct the NAP to use the tympanic thermometer?

Using Evidence in Nursing Practice

Communication and Collaboration

Documentation and Informatics

Patient Safety and Quality Improvement

Infection Control

Health Assessment

Specimen Collection

Diagnostic Procedures

Bathing and Personal Hygiene

Care of the Eye and Ear

Promoting Nutrition

Pain Management

Promoting Oxygenation

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Traction, cast Care, and Immobilization Devices

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preparation for Safe Medication Administration

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Wound Care and Irrigation

Pressure Ulcers

Dressings,bandages,and Binders

Intravenous and Vascular Access Therapy

Preoperative and Postoperative Care

Emergency Measures for Life Support in the Hospital Setting

Palliative Care

Home Care Safety

Filters

Exam 6: Vital Signs

The nurse is going to measure the patient's pulse oxygen saturation.She knows pulse oximetry readings can be influenced by several factors.(Select all that apply.)

The nurse is caring for a lethargic,18-year-old patient with a respiratory rate of 32 breaths per minute.What is the first action the nurse should take?

A patient has been experiencing some circulatory issues,and an apical-radial pulse is ordered.Nursing care is correct if which procedure is followed?

At what distance above the antecubital fossa does the nurse position a blood pressure (BP)cuff when using the brachial artery to measure BP?

The nurse is running a blood pressure screening clinic at the community health center.Which action should the nurse implement to obtain an accurate measurement of a patient's blood pressure on an upper extremity?

You have delegated the task of obtaining a pulse oximetry reading to the NAP.Which of the following statements by the NAP indicates a need for further education?

The nurse delegates temperature measurement to nursing assistive personnel (NAP).For which patient should the nurse instruct the NAP to use the tympanic thermometer?

Using Evidence in Nursing Practice

Communication and Collaboration

Documentation and Informatics

Patient Safety and Quality Improvement

Infection Control

Health Assessment

Specimen Collection

Diagnostic Procedures

Bathing and Personal Hygiene

Care of the Eye and Ear

Promoting Nutrition

Pain Management

Promoting Oxygenation

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Traction, cast Care, and Immobilization Devices

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preparation for Safe Medication Administration

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Wound Care and Irrigation

Pressure Ulcers

Dressings,bandages,and Binders

Intravenous and Vascular Access Therapy

Preoperative and Postoperative Care

Emergency Measures for Life Support in the Hospital Setting

Palliative Care

Home Care Safety

Filters