Question 1

A nurse assesses a patient's dorsalis pedis pulse.The pulse is difficult to feel and not palpable when only slight pressure is applied.How should the nurse document this finding?

Accepted Answer

A) Weak pulse 
B) Normal pulse 
C) Thready pulse 
D) Bounding pulse 
A) Weak pulse 
B) Normal pulse 
C) Thready pulse 
D) Bounding pulse

Question 2

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures.What temperature is the nurse aware of that can lead to death?

Accepted Answer

A) 95.2°F (35.1°
C)  
B) 93.0°F (33.8°
C)  
C) 93.2°F (34°
C)  
D) 90.8°F (32.6°
C)  
A) 95.2°F (35.1°
C)  
B) 93.0°F (33.8°
C)  
C) 93.2°F (34°
C)  
D) 90.8°F (32.6°
C)

Question 3

A nurse assesses a neonate's temperature by using a temporal artery scanner.What intervention should the nurse implement if the neonate's temperature is 96°F (35.5°C)?

Accepted Answer

A) Record the findings. 
B) Notify the health care provider. 
C) Check the axillary temperature. 
D) Check the tympanic temperature. 
A) Record the findings. 
B) Notify the health care provider. 
C) Check the axillary temperature. 
D) Check the tympanic temperature.

Question 4

A nurse assesses a patient's dorsalis pedis pulse.The pulse is not palpable when light pressure is applied.How should the nurse document this finding?

Accepted Answer

A) Weak pulse 
B) Normal pulse 
C) Thready pulse 
D) Bounding pulse 
A) Weak pulse 
B) Normal pulse 
C) Thready pulse 
D) Bounding pulse

Question 5

If a patient has an axillary temperature of 96.2°F (35.6°C),the nurse understands that the true temperature is ______.

Accepted Answer

97.2°F (35.6°C)
97.2°F
35.6°C

Question 6

What does the nurse use the diaphragm of the stethoscope to best assess?

Accepted Answer

A) Carotid sounds 
B) Lung sounds 
C) Vascular sounds 
D) Low-pitched sounds 
A) Carotid sounds 
B) Lung sounds 
C) Vascular sounds 
D) Low-pitched sounds

Question 7

The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement.What information should the nurse provide regarding this procedure? (Select all that apply.)

Accepted Answer

A) Expect precise values. 
B) Proper measurement techniques are necessary. 
C) Cuff fits over clothing. 
D) Stethoscope is not required. 
E) Recalibration is not necessary. 
A) Expect precise values. 
B) Proper measurement techniques are necessary. 
C) Cuff fits over clothing. 
D) Stethoscope is not required. 
E) Recalibration is not necessary.

Question 8

The patient's pulse is below 60 beats/min.The nurse is aware that the patient is not receiving digoxin.What does the nurse suspect is causing the bradycardia?

Accepted Answer

A) Low exercise tolerance 
B) Unrelieved severe pain 
C) Excessive bed rest 
D) A prone position 
A) Low exercise tolerance 
B) Unrelieved severe pain 
C) Excessive bed rest 
D) A prone position

Question 9

The nurse assesses respirations of a patient demonstrating pursed-lip breathing,flared nostrils,and retractions.How will the nurse describe these respirations?

Accepted Answer

A) Tachypnea 
B) Stertorous 
C) Dyspnea 
D) Cheyne-Stokes 
A) Tachypnea 
B) Stertorous 
C) Dyspnea 
D) Cheyne-Stokes

Question 10

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

Accepted Answer

A) Backward 
B) Parallel to the ears 
C) Toward the face 
D) Downward 
A) Backward 
B) Parallel to the ears 
C) Toward the face 
D) Downward

Exam 12: Vital Signs

A nurse assesses a patient's dorsalis pedis pulse.The pulse is difficult to feel and not palpable when only slight pressure is applied.How should the nurse document this finding?

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures.What temperature is the nurse aware of that can lead to death?

A nurse assesses a neonate's temperature by using a temporal artery scanner.What intervention should the nurse implement if the neonate's temperature is 96°F (35.5°C)?

A nurse assesses a patient's dorsalis pedis pulse.The pulse is not palpable when light pressure is applied.How should the nurse document this finding?

If a patient has an axillary temperature of 96.2°F (35.6°C),the nurse understands that the true temperature is ______.

What does the nurse use the diaphragm of the stethoscope to best assess?

The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement.What information should the nurse provide regarding this procedure? (Select all that apply.)

The patient's pulse is below 60 beats/min.The nurse is aware that the patient is not receiving digoxin.What does the nurse suspect is causing the bradycardia?

The nurse assesses respirations of a patient demonstrating pursed-lip breathing,flared nostrils,and retractions.How will the nurse describe these respirations?

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

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