Medical-Surgical Nursing Concepts for Inter
professional Collaborative Care 10th Edition by
Donna Ignatavicius, Complete Questions and
Answers Grade A+
✓ A client who was recently admitted and reports chest pain
a nurse is planning care for a group of clients and is delegating to the assistive personnel
(ap) to take the clients' vital signs. for which of the following clients should the nurse obtain
the vital signs rather than the ap?
✓ Increase in BP
A nurse is caring for a client who has an increase in cardiac output. Which of the following
findings should the nurse expect?
✓ All except increase fluid intake
A nurse is contributing to the plan of care for a client who has hypertension. Which of the
following interventions should the nurse recommend? (Select all that apply.)
✓ 8-year-old male: respiratory rate 34/min, SaO2 97%
A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained
by an assistive personnel. From which of the following clients should the nurse collect data
and recheck the vital signs prior to notifying the provider?
✓ smoking
A nurse is caring for a client who asks about factors that could cause their pulse rate to
increase. Which of the following factors should the nurse include in their response?
✓ Recording vital signs provides critical information regarding a client's condition
A charge nurse is teaching a group of assistive personnel (AP) about the importance of
documenting accurate vital signs. Which of the following information should the charge
nurse include in the teaching?
✓ Fever can increase a clients respiratory rate
1|Page
,A nurse is contributing to the planning of an in-service about factors affecting respiratory
rate for a group of assistive personnel. Which of the following information should the nurse
recommend be included?
✓ A temporal probe thermometer uses infrared scanning to determine a client's
temperature
A nurse is assisting in the planning of an in-service for a group of newly hired assistive
personnel (AP) about body temperature. Which of the following information should the
nurse recommend be included?
✓ Administer an antipyretic medication
A nurse is contributing to the plan of care for a client who has a temperature of 39.1° C
(102.4° F). Which of the following interventions should the nurse include?
✓ Encourage the client to practice relaxation techniques each day
A nurse is contributing to the plan of care for a client who is experiencing tachycardia.
Which of the following interventions should the nurse plan to recommend?
✓ A client who is diaphoretic and frequently chewing ice to relieve dry mouth
A nurse is planning care for a group of clients. For which of the following clients should the
nurse direct an assistive personnel (AP) to obtain a rectal temperature?
✓ An 11- year old child who has a respiratory rate of 34/min
A nurse is obtaining vital signs for a group of clients. Which of the following findings requires
intervention?
✓ A school-age child who has a respiratory rate of 14/min
A nurse is caring for a group of clients. Which of the following clients is experiencing an
alteration in their respiratory rate that requires intervention?
✓ Place the stethoscope over the 4th intercostal space to the left of the sternum
A nurse is collecting data from a 3-month-old infant during a well-child visit. Which of the
following actions should the nurse take when checking the infant's apical pulse?
2|Page
, ✓ Obtain a manual blood pressure reading from the client
A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the
following actions should the nurse take next?
✓ A 52-year-old client who has an SaO2 of 92%
A nurse is reviewing the recent vital signs of a group of clients. Which of the following
clients should the nurse see first?
✓ Apex of the heart
A nurse is preparing to obtain a young adult client's apical pulse. In which of the following
locations should the nurse place their stethoscope to auscultate the client's pulse?
✓ Encourage the client to reduce intake of caffeinated soft drinks
A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions
should the nurse take to improve the client's heart rate?
✓ A client who has stablized BP measurements
A nurse is reinforcing teaching with a group of assistive personnel (AP) about techniques
used to obtain BP. For which of the following clients should the nurse to instruct the AP to
obtain an electronic BP measurement?
✓ Oxygen saturation reflects the amount of oxygen being delivered to tissues
A nurse is discussing oxygen saturation with a client. Which of the following information
should the nurse include?
✓ less than 2 seconds
A capillary refill time of ___ ____ ___ ______ indicates adequate peripheral perfusion and
ensures a reliable oxygen saturation measurement.
✓ Oxygen saturation reflects the amount of oxygen bound to the
hemoglobin of red blood cells.
✓ oxygen saturation
3|Page
professional Collaborative Care 10th Edition by
Donna Ignatavicius, Complete Questions and
Answers Grade A+
✓ A client who was recently admitted and reports chest pain
a nurse is planning care for a group of clients and is delegating to the assistive personnel
(ap) to take the clients' vital signs. for which of the following clients should the nurse obtain
the vital signs rather than the ap?
✓ Increase in BP
A nurse is caring for a client who has an increase in cardiac output. Which of the following
findings should the nurse expect?
✓ All except increase fluid intake
A nurse is contributing to the plan of care for a client who has hypertension. Which of the
following interventions should the nurse recommend? (Select all that apply.)
✓ 8-year-old male: respiratory rate 34/min, SaO2 97%
A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained
by an assistive personnel. From which of the following clients should the nurse collect data
and recheck the vital signs prior to notifying the provider?
✓ smoking
A nurse is caring for a client who asks about factors that could cause their pulse rate to
increase. Which of the following factors should the nurse include in their response?
✓ Recording vital signs provides critical information regarding a client's condition
A charge nurse is teaching a group of assistive personnel (AP) about the importance of
documenting accurate vital signs. Which of the following information should the charge
nurse include in the teaching?
✓ Fever can increase a clients respiratory rate
1|Page
,A nurse is contributing to the planning of an in-service about factors affecting respiratory
rate for a group of assistive personnel. Which of the following information should the nurse
recommend be included?
✓ A temporal probe thermometer uses infrared scanning to determine a client's
temperature
A nurse is assisting in the planning of an in-service for a group of newly hired assistive
personnel (AP) about body temperature. Which of the following information should the
nurse recommend be included?
✓ Administer an antipyretic medication
A nurse is contributing to the plan of care for a client who has a temperature of 39.1° C
(102.4° F). Which of the following interventions should the nurse include?
✓ Encourage the client to practice relaxation techniques each day
A nurse is contributing to the plan of care for a client who is experiencing tachycardia.
Which of the following interventions should the nurse plan to recommend?
✓ A client who is diaphoretic and frequently chewing ice to relieve dry mouth
A nurse is planning care for a group of clients. For which of the following clients should the
nurse direct an assistive personnel (AP) to obtain a rectal temperature?
✓ An 11- year old child who has a respiratory rate of 34/min
A nurse is obtaining vital signs for a group of clients. Which of the following findings requires
intervention?
✓ A school-age child who has a respiratory rate of 14/min
A nurse is caring for a group of clients. Which of the following clients is experiencing an
alteration in their respiratory rate that requires intervention?
✓ Place the stethoscope over the 4th intercostal space to the left of the sternum
A nurse is collecting data from a 3-month-old infant during a well-child visit. Which of the
following actions should the nurse take when checking the infant's apical pulse?
2|Page
, ✓ Obtain a manual blood pressure reading from the client
A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the
following actions should the nurse take next?
✓ A 52-year-old client who has an SaO2 of 92%
A nurse is reviewing the recent vital signs of a group of clients. Which of the following
clients should the nurse see first?
✓ Apex of the heart
A nurse is preparing to obtain a young adult client's apical pulse. In which of the following
locations should the nurse place their stethoscope to auscultate the client's pulse?
✓ Encourage the client to reduce intake of caffeinated soft drinks
A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions
should the nurse take to improve the client's heart rate?
✓ A client who has stablized BP measurements
A nurse is reinforcing teaching with a group of assistive personnel (AP) about techniques
used to obtain BP. For which of the following clients should the nurse to instruct the AP to
obtain an electronic BP measurement?
✓ Oxygen saturation reflects the amount of oxygen being delivered to tissues
A nurse is discussing oxygen saturation with a client. Which of the following information
should the nurse include?
✓ less than 2 seconds
A capillary refill time of ___ ____ ___ ______ indicates adequate peripheral perfusion and
ensures a reliable oxygen saturation measurement.
✓ Oxygen saturation reflects the amount of oxygen bound to the
hemoglobin of red blood cells.
✓ oxygen saturation
3|Page
