Question 1

_____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

Accepted Answer

Hypotension
Hypotension occurs when the systolic blood pressure falls to 90 mm Hg or below.Although some adults normally have a low blood pressure,for most people,low blood pressure is an abnormal finding associated with illness.

Question 2

___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.

Accepted Answer

S1
S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling,just before systolic contraction begins.

Question 3

What steps should the nurse take to conduct an assessment of a possible pulse deficit?

Accepted Answer

A) A nurse measures the pulse after the patient exercises. 
B) Two nurses check the same pulse on opposite sides of the body. 
C) Two nurses assess the apical and radial pulses and determine the difference. 
D) The current pulse is compared with previous pulse measurements for differences. 
A) A nurse measures the pulse after the patient exercises. 
B) Two nurses check the same pulse on opposite sides of the body. 
C) Two nurses assess the apical and radial pulses and determine the difference. 
D) The current pulse is compared with previous pulse measurements for differences. C

Question 4

The nurse is about to take a patient's blood pressure.Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply. )

Accepted Answer

A) Bladder or cuff too narrow 
B) Bladder or cuff too wide 
C) Patient's arm below the level of the heart 
D) Inflating the cuff too slowly 
A) Bladder or cuff too narrow 
B) Bladder or cuff too wide 
C) Patient's arm below the level of the heart 
D) Inflating the cuff too slowly

Question 5

_________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

Accepted Answer

S2
S2 is the sound of the pulm

Question 6

An irregular heartbeat,often found in children,that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

Accepted Answer

dysrhythmia
Children often hav

Question 7

The nurse is preparing to take the patient's temperature.Which of the following may cause the temperature to fluctuate? (Select all that apply. )

Accepted Answer

A) Age 
B) Stress 
C) Hormones 
D) Medications 
A) Age 
B) Stress 
C) Hormones 
D) Medications

Question 8

The patient is returning from a cardiac catheterization.The puncture site is in the right femoral artery.The patient is having vital signs assessed every 15 minutes.Along with vital signs,the nurse assesses the pedal pulses of the right and left feet.Which of the following would be of major concern?

Accepted Answer

A) Both pedal pulses were bounding. 
B) The femoral artery could be palpated. 
C) The right pedal pulse was weaker than the left. 
D) The radial artery pulse was 88. 
A) Both pedal pulses were bounding. 
B) The femoral artery could be palpated. 
C) The right pedal pulse was weaker than the left. 
D) The radial artery pulse was 88.

Question 9

The patient is brought to the emergency department complaining of severe shortness of breath.She is cyanotic and her extremities are cold.In an attempt to quickly assess the patient's respiratory status,the nurse should:

Accepted Answer

A) remove the patient's nail polish to get a pulse oximetry reading. 
B) use a forehead probe to get a pulse oximetry reading. 
C) use a finger probe to get a pulse oximetry reading. 
D) check the color of the patient's nail polish before attempting a reading. 
A) remove the patient's nail polish to get a pulse oximetry reading. 
B) use a forehead probe to get a pulse oximetry reading. 
C) use a finger probe to get a pulse oximetry reading. 
D) check the color of the patient's nail polish before attempting a reading.

Question 10

The nurse is taking a rectal temperature on an adult patient.She expects to insert the thermometer __________ inches.

Accepted Answer

1.5
Gently insert the thermome

Question 11

When evaluating the radial pulse measurement technique of the nursing assistant,the nurse identifies appropriate technique when the assistant:

Accepted Answer

A) has the patient's arm elevated. 
B) positions the patient supine or sitting. 
C) applies significant pressure to the pulse site. 
D) counts the pulse for 15 seconds and multiplies by 4. 
A) has the patient's arm elevated. 
B) positions the patient supine or sitting. 
C) applies significant pressure to the pulse site. 
D) counts the pulse for 15 seconds and multiplies by 4.

Question 12

The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations.This type of device is known as a(n)_____ manometer.

Accepted Answer

A) mercury 
B) electronic 
C) aneroid 
D) direct (invasive) 
A) mercury 
B) electronic 
C) aneroid 
D) direct (invasive)

Question 13

An appropriate procedure for measurement of an adult's temperature with a tympanic membrane sensor is:

Accepted Answer

A) pulling the ear pinna down and back. 
B) moving into the ear in a figure-eight pattern. 
C) fitting the probe loosely into the ear canal. 
D) pointing the probe toward the mouth and chin. 
A) pulling the ear pinna down and back. 
B) moving into the ear in a figure-eight pattern. 
C) fitting the probe loosely into the ear canal. 
D) pointing the probe toward the mouth and chin.

Question 14

The patient has been in the hospital for several days for urosepsis.He has been responding favorably to treatment,and his vital signs have been "normal" for 2 days.When the nurse takes his vital signs,however,the patient's apical pulse is 152 and regular.The nurse suspects that the:

Accepted Answer

A) patient is having a reaction to his narcotic medication. 
B) patient may be suffering from hypothermia. 
C) patient's fever may have returned. 
D) patient may be an athlete. 
A) patient is having a reaction to his narcotic medication. 
B) patient may be suffering from hypothermia. 
C) patient's fever may have returned. 
D) patient may be an athlete.

Question 15

During the normal cardiac cycle,blood pressure reaches a peak,followed by a trough,in the cycle.What is the peak known as?

Accepted Answer

A) Pulse pressure 
B) Systolic cycle 
C) Diastolic cycle 
D) Korotkoff phase 
A) Pulse pressure 
B) Systolic cycle 
C) Diastolic cycle 
D) Korotkoff phase

Question 16

Which site is used to auscultate blood pressure?

Accepted Answer

A) Radial 
B) Ulnar 
C) Brachial 
D) Temporal 
A) Radial 
B) Ulnar 
C) Brachial 
D) Temporal

Question 17

The nurse is caring for an infant in the NICU.While taking vital signs,the nurse finds that the baby's heart rate is 195.The nurse calls the physician,knowing that the normal heart rate should be:

Accepted Answer

A) 60 to 100 beats per minute. 
B) 100 to 160 beats per minute. 
C) 90 to 140 beats per minute. 
D) 220 beats per minute or higher. 
A) 60 to 100 beats per minute. 
B) 100 to 160 beats per minute. 
C) 90 to 140 beats per minute. 
D) 220 beats per minute or higher.

Question 18

The patient is an 86-year-old woman who is being admitted for dehydration and pneumonia.The patient is lying in bed but tells the nurse that she needs to go to the bathroom.The nurse tells the patient that she will stay with her and will help her get there.The patient states,"That's OK.I can make it on my own." The nurse should:

Accepted Answer

A) help the patient to the bathroom and stay with her. 
B) allow the patient to get up on her own and go to the bathroom. 
C) allow the patient to go to the bathroom and call for help if needed. 
D) insert a Foley catheter. 
A) help the patient to the bathroom and stay with her. 
B) allow the patient to get up on her own and go to the bathroom. 
C) allow the patient to go to the bathroom and call for help if needed. 
D) insert a Foley catheter.

Question 19

The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy.To take the patient's vital signs and to accurately assess the patient's blood pressure,it will be necessary to:

Accepted Answer

A) place the blood pressure cuff on the left upper arm. 
B) place the blood pressure cuff on the right upper arm. 
C) place the blood pressure cuff on the right lower arm. 
D) use direct (invasive)blood pressure measurement. 
A) place the blood pressure cuff on the left upper arm. 
B) place the blood pressure cuff on the right upper arm. 
C) place the blood pressure cuff on the right lower arm. 
D) use direct (invasive)blood pressure measurement.

Question 20

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

Accepted Answer

pulse deficit
An inefficient contraction

Exam 5: Vital Signs

_____________ occurs when the systolic blood pressure falls to 90 mm Hg or below.

___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.

What steps should the nurse take to conduct an assessment of a possible pulse deficit?

The nurse is about to take a patient's blood pressure.Which of the following conditions would cause the nurse to obtain a false high reading? (Select all that apply. )

_________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

An irregular heartbeat,often found in children,that speeds up with inspiration and slows down with expiration is known as a sinus ___________.

The nurse is preparing to take the patient's temperature.Which of the following may cause the temperature to fluctuate? (Select all that apply. )

The patient is brought to the emergency department complaining of severe shortness of breath.She is cyanotic and her extremities are cold.In an attempt to quickly assess the patient's respiratory status,the nurse should:

The nurse is taking a rectal temperature on an adult patient.She expects to insert the thermometer __________ inches.

When evaluating the radial pulse measurement technique of the nursing assistant,the nurse identifies appropriate technique when the assistant:

The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations.This type of device is known as a(n)_____ manometer.

An appropriate procedure for measurement of an adult's temperature with a tympanic membrane sensor is:

The patient has been in the hospital for several days for urosepsis.He has been responding favorably to treatment,and his vital signs have been "normal" for 2 days.When the nurse takes his vital signs,however,the patient's apical pulse is 152 and regular.The nurse suspects that the:

During the normal cardiac cycle,blood pressure reaches a peak,followed by a trough,in the cycle.What is the peak known as?

Which site is used to auscultate blood pressure?

The nurse is caring for an infant in the NICU.While taking vital signs,the nurse finds that the baby's heart rate is 195.The nurse calls the physician,knowing that the normal heart rate should be:

The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy.To take the patient's vital signs and to accurately assess the patient's blood pressure,it will be necessary to:

An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a ____________.

Using Evidence in Practice

Admitting, Transfer, and Discharge

Communication and Collaboration

Documentation and Informatics

Health Assessment

Specimen Collection

Diagnostic Procedures

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Disaster Preparedness

Pain Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Intravenous and Vascular Access Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preoperative and Postoperative Care

Intraoperative Care

Pressure Injury Prevention and Care

Wound Care and Irrigations

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

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