NURS 5001 HEALTH ASSESSMENT
CLINICAL SKILLS MODULE EXAM
QUESTIONS WITH CORRECT
ANSWERS
What is the nurse's priority action if a patient's radial pulse has an irregular rhythm?
A. Reassess the pulse for 1 full minute.
B. Assess the patient for a pulse deficit.
C. Wait 5 minutes, and then reassess the pulse.
D. Review documentation regarding an irregular rhythm. - Answer-B. Assess the
patient for a pulse deficit.
Rationale: Assessing the patient for a pulse deficit is useful in identifying an
alteration in cardiac output. Although reassessing the pulse is appropriate, this is not
the priority action because the presence of an irregular rhythm has already been
established. Waiting 5 minutes to reassess the radial pulse is not appropriate and
could be dangerous for the patient in some unstable cardiac conditions. Reviewing
documentation is not the priority action because establishing a history of an irregular
heartbeat is not essential.
Inadequate oxygenation to the body will cause the radial pulse to become:
A. Tachycardic
B. Bradycardic
C. Irregular
D. Bounding - Answer-A. Tachycardic
Rationale: The heart rate will increase to circulate more available oxygen to tissues.
Tachycardia is more than 100 beats/minute. The heart rate will increase, not
decrease. Bradycardia is less than 60 beats/minute. Heart rhythm (regular or
irregular) is determined by the electrical conduction through the heart, not
oxygenation. A bounding pulse indicates increased blood volume ejected against the
arterial wall.
Which action would best assess the effect of exercise on a patient's radial pulse
measurement?
A. Measuring the patient's radial pulse before and after exercise.
B. Assessing the patient's radial pulse 30 minutes after exercise.
C. Comparing the patient's radial and apical pulses after exercise.
D. Comparing the patient's pre-exercise radial and post-exercise apical pulses. -
Answer-A. Measuring the patient's radial pulse before and after exercise.
Rationale: Measuring the patient's radial pulse before and after exercise best
assesses the effect of the exercise on the radial pulse because it compares the
,same pulse site before and after exercise. Thirty minutes after exercise is too long to
wait to obtain useful information about the effect of exercise on the patient's radial
pulse. Assessing the patient's apical pulse will not determine the effect of exercise
on the radial pulse. Assessing the patient's apical pulse, whether pre-exercise or
post-exercise assessment, will not determine the effect of exercise on the radial
pulse.
Which action can the nurse take to keep a patient from consciously controlling his or
her breathing during an assessment?
A. Take the patient's temperature while counting the respiratory rate.
B. Assess respiration after measuring the pulse.
C. Assess respiration after taking the blood pressure.
D. Assess respiration before measuring the blood pressure. - Answer-B. Assess
respiration after measuring the pulse.
Rationale: Assess respiration after measuring the pulse, so that the patient will not
try to voluntarily control his or her breathing. Taking the patient's temperature while
counting the respiratory rate and assessing respiration before or after taking the
blood pressure will not prevent the patient from consciously controlling breathing
during an assessment.
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths
per minute. What should the nurse do when conducting the next assessment of this
patient's respiratory rate?
A. Count breaths for 10 seconds and multiply by 6.
B. Count breaths for 15 seconds and multiply by 4
C. Count breaths for 30 seconds and multiply by 2.
D. Count breaths for 60 seconds. - Answer-D. Count breaths for 60 seconds.
Rationale: The nurse should count the patient's breaths for a full 60 seconds,
because her respiratory rate is less than 12 breaths per minute.
When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory cycle?
A. The number of inspirations per minute.
B. The number of expirations per minute.
C. The number of sighs per minute.
D. The number of inspirations and expirations per minute. - Answer-D. The number
of inspirations and expirations per minute.
Rationale: A complete respiratory cycle consists of one inspiration and one
expiration. An inspiration is only one half of a respiratory cycle. An expiration is only
one half of a respiratory cycle. The number of sighs per minute is not a respiratory
cycle. Sighs are not included in the count of respiratory cycles.
,During the assessment of a patient's respiratory rate, when the second hand reaches
the 15-second mark, the respiratory count is 8. What should the nurse do at this
time?
A. Stop the assessment.
B. Stop the assessment, and multiply the number 8 by 2.
C. Stop the assessment, and multiply the number 8 by 6.
D. Continue to count the patient's breaths for a full 60 seconds. - Answer-D.
Continue to count the patient's breaths for a full 60 seconds.
Rationale: At 8 breaths in the first 15 seconds, the patient has a rapid respiratory
rate of more than 20 breaths per minute. The nurse should continue to count the
breaths for a full 60 seconds. The nurse should not stop the assessment. Multiplying
the 15-second respiratory rate by 2 would calculate the respiratory rate for only 30
seconds, not the full 60 seconds required when the respiratory rate is rapid.
Multiplying the 15-second respiratory rate by 6 is not the correct way to calculate a
patient's respiratory rate.
The nurse plans to assess a patient's respiratory rate; however, the patient has just
returned from ambulating to the bathroom. What should the nurse do to minimize the
effect of exercise on the patient's respiratory rate?
A. Assess the pulse for a full 60 seconds before assessing respiration.
B. Encourage the patient to rest for 10 minutes before assessing respiration.
C. Compare the postexercise respiratory rate with his baseline findings.
D. Compare the postexercise findings with the previous at-rest findings.
Submit Test - Answer-B. Encourage the patient to rest for 10 minutes before
assessing respiration.
Rationale: Waiting 10 minutes before assessing respiration allows the patient's
oxygen demand to return to pre-exercise levels. The effects of exercise on the
respiratory rate will most likely be present after 1 minute. Comparing the
postexercise respiratory rate with the baseline or previous at-rest findings will not
minimize the effect of exercise on the patient's respiratory rate. Such a comparison
will not minimize the effect of exercise on the patient's respiratory rate.
The nurse is planning to measure a patient's blood pressure. What does the systolic
measurement represent?
A. Minimal pressure on the arterial walls.
B. The pressure exerted against the arterial wall.
C. The change in pressure from a lying to a sitting position.
D. The last sound heard when measuring the blood pressure. - Answer-B. The
pressure exerted against the arterial wall.
Rationale: The systolic blood pressure measurement represents the pressure of
blood exerted against the arterial wall. The diastolic blood pressure measurement
represents the minimal pressure exerted against the arterial walls at all times. A
change in pressure from a lying to a sitting position is an orthostatic blood pressure
, change. The sounds heard during blood pressure measurement are the Korotkoff
sounds. The first sound identifies the systolic blood pressure.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings?
A. The blood pressure cuff is too wide for arm circumference.
B. The bladder was deflated too slowly.
C. The patient's arm was not supported while the measurement was taken.
D. The blood pressure cuff was not wrapped evenly around the arm. - Answer-A.
The blood pressure cuff is too wide for arm circumference.
Rationale: A wide blood pressure cuff can result in a false low blood pressure
reading. The bladder deflated too slowly can result in a false high diastolic blood
pressure reading. A patient's arm not being supported can result in a false high blood
pressure reading. A blood pressure cuff not wrapped evenly around the arm can
result in a false high blood pressure reading.
What should the nurse do if the patient's blood pressure is not within normal limits?
A. Review the blood pressure readings in the patient's record.
B. Assess for proper cuff size and arm positioning.
C. Promptly report the assessment data to the nurse in charge or to the health care
provider.
D. Encourage the patient to rest quietly in bed for 30 minutes, and then retake the
blood pressure. - Answer-C. Promptly report the assessment data to the nurse in
charge or to the health care provider.
Rationale: Promptly reporting the assessment data to the nurse in charge is the
correct response, because the patient must be assessed for possible cardiovascular
problems. Reviewing the blood pressure readings in the patient's record is not the
correct response, because a blood pressure reading outside of normal limits must be
reported without delay to the nurse in charge or to the health care provider. The
nurse would have assessed for proper cuff size and positioned the arm correctly
before measuring the blood pressure. Encouraging the patient to rest quietly in bed
for 30 minutes, and then retake the blood pressure is not the correct response. A
blood pressure reading outside of normal limits must be reported without delay to the
nurse in charge or to the health care provider.
What would the nurse do to prevent the spread of infection when assessing a
patient's blood pressure?
A. Wear gloves.
B. Avoid using an arm in which an intravenous catheter has been inserted.
C. Clean the stethoscope with alcohol before and after using it.
D. Inflate the cuff 30 mm higher than the expected systolic pressure. - Answer-C.
Clean the stethoscope with alcohol before and after using it.
CLINICAL SKILLS MODULE EXAM
QUESTIONS WITH CORRECT
ANSWERS
What is the nurse's priority action if a patient's radial pulse has an irregular rhythm?
A. Reassess the pulse for 1 full minute.
B. Assess the patient for a pulse deficit.
C. Wait 5 minutes, and then reassess the pulse.
D. Review documentation regarding an irregular rhythm. - Answer-B. Assess the
patient for a pulse deficit.
Rationale: Assessing the patient for a pulse deficit is useful in identifying an
alteration in cardiac output. Although reassessing the pulse is appropriate, this is not
the priority action because the presence of an irregular rhythm has already been
established. Waiting 5 minutes to reassess the radial pulse is not appropriate and
could be dangerous for the patient in some unstable cardiac conditions. Reviewing
documentation is not the priority action because establishing a history of an irregular
heartbeat is not essential.
Inadequate oxygenation to the body will cause the radial pulse to become:
A. Tachycardic
B. Bradycardic
C. Irregular
D. Bounding - Answer-A. Tachycardic
Rationale: The heart rate will increase to circulate more available oxygen to tissues.
Tachycardia is more than 100 beats/minute. The heart rate will increase, not
decrease. Bradycardia is less than 60 beats/minute. Heart rhythm (regular or
irregular) is determined by the electrical conduction through the heart, not
oxygenation. A bounding pulse indicates increased blood volume ejected against the
arterial wall.
Which action would best assess the effect of exercise on a patient's radial pulse
measurement?
A. Measuring the patient's radial pulse before and after exercise.
B. Assessing the patient's radial pulse 30 minutes after exercise.
C. Comparing the patient's radial and apical pulses after exercise.
D. Comparing the patient's pre-exercise radial and post-exercise apical pulses. -
Answer-A. Measuring the patient's radial pulse before and after exercise.
Rationale: Measuring the patient's radial pulse before and after exercise best
assesses the effect of the exercise on the radial pulse because it compares the
,same pulse site before and after exercise. Thirty minutes after exercise is too long to
wait to obtain useful information about the effect of exercise on the patient's radial
pulse. Assessing the patient's apical pulse will not determine the effect of exercise
on the radial pulse. Assessing the patient's apical pulse, whether pre-exercise or
post-exercise assessment, will not determine the effect of exercise on the radial
pulse.
Which action can the nurse take to keep a patient from consciously controlling his or
her breathing during an assessment?
A. Take the patient's temperature while counting the respiratory rate.
B. Assess respiration after measuring the pulse.
C. Assess respiration after taking the blood pressure.
D. Assess respiration before measuring the blood pressure. - Answer-B. Assess
respiration after measuring the pulse.
Rationale: Assess respiration after measuring the pulse, so that the patient will not
try to voluntarily control his or her breathing. Taking the patient's temperature while
counting the respiratory rate and assessing respiration before or after taking the
blood pressure will not prevent the patient from consciously controlling breathing
during an assessment.
On the last assessment of a patient's respiration, her respiratory rate was 10 breaths
per minute. What should the nurse do when conducting the next assessment of this
patient's respiratory rate?
A. Count breaths for 10 seconds and multiply by 6.
B. Count breaths for 15 seconds and multiply by 4
C. Count breaths for 30 seconds and multiply by 2.
D. Count breaths for 60 seconds. - Answer-D. Count breaths for 60 seconds.
Rationale: The nurse should count the patient's breaths for a full 60 seconds,
because her respiratory rate is less than 12 breaths per minute.
When measuring a patient's respiratory rate, the nurse will count the number of
completed respiratory cycles per minute. What is the definition of a respiratory cycle?
A. The number of inspirations per minute.
B. The number of expirations per minute.
C. The number of sighs per minute.
D. The number of inspirations and expirations per minute. - Answer-D. The number
of inspirations and expirations per minute.
Rationale: A complete respiratory cycle consists of one inspiration and one
expiration. An inspiration is only one half of a respiratory cycle. An expiration is only
one half of a respiratory cycle. The number of sighs per minute is not a respiratory
cycle. Sighs are not included in the count of respiratory cycles.
,During the assessment of a patient's respiratory rate, when the second hand reaches
the 15-second mark, the respiratory count is 8. What should the nurse do at this
time?
A. Stop the assessment.
B. Stop the assessment, and multiply the number 8 by 2.
C. Stop the assessment, and multiply the number 8 by 6.
D. Continue to count the patient's breaths for a full 60 seconds. - Answer-D.
Continue to count the patient's breaths for a full 60 seconds.
Rationale: At 8 breaths in the first 15 seconds, the patient has a rapid respiratory
rate of more than 20 breaths per minute. The nurse should continue to count the
breaths for a full 60 seconds. The nurse should not stop the assessment. Multiplying
the 15-second respiratory rate by 2 would calculate the respiratory rate for only 30
seconds, not the full 60 seconds required when the respiratory rate is rapid.
Multiplying the 15-second respiratory rate by 6 is not the correct way to calculate a
patient's respiratory rate.
The nurse plans to assess a patient's respiratory rate; however, the patient has just
returned from ambulating to the bathroom. What should the nurse do to minimize the
effect of exercise on the patient's respiratory rate?
A. Assess the pulse for a full 60 seconds before assessing respiration.
B. Encourage the patient to rest for 10 minutes before assessing respiration.
C. Compare the postexercise respiratory rate with his baseline findings.
D. Compare the postexercise findings with the previous at-rest findings.
Submit Test - Answer-B. Encourage the patient to rest for 10 minutes before
assessing respiration.
Rationale: Waiting 10 minutes before assessing respiration allows the patient's
oxygen demand to return to pre-exercise levels. The effects of exercise on the
respiratory rate will most likely be present after 1 minute. Comparing the
postexercise respiratory rate with the baseline or previous at-rest findings will not
minimize the effect of exercise on the patient's respiratory rate. Such a comparison
will not minimize the effect of exercise on the patient's respiratory rate.
The nurse is planning to measure a patient's blood pressure. What does the systolic
measurement represent?
A. Minimal pressure on the arterial walls.
B. The pressure exerted against the arterial wall.
C. The change in pressure from a lying to a sitting position.
D. The last sound heard when measuring the blood pressure. - Answer-B. The
pressure exerted against the arterial wall.
Rationale: The systolic blood pressure measurement represents the pressure of
blood exerted against the arterial wall. The diastolic blood pressure measurement
represents the minimal pressure exerted against the arterial walls at all times. A
change in pressure from a lying to a sitting position is an orthostatic blood pressure
, change. The sounds heard during blood pressure measurement are the Korotkoff
sounds. The first sound identifies the systolic blood pressure.
You have assigned a new nursing assistive personnel (NAP) to take routine vital
signs. You notice that the NAP's last three patients have had unusually low blood
pressure that you have had to confirm. What is the most likely reason the NAP is
obtaining falsely low blood pressure readings?
A. The blood pressure cuff is too wide for arm circumference.
B. The bladder was deflated too slowly.
C. The patient's arm was not supported while the measurement was taken.
D. The blood pressure cuff was not wrapped evenly around the arm. - Answer-A.
The blood pressure cuff is too wide for arm circumference.
Rationale: A wide blood pressure cuff can result in a false low blood pressure
reading. The bladder deflated too slowly can result in a false high diastolic blood
pressure reading. A patient's arm not being supported can result in a false high blood
pressure reading. A blood pressure cuff not wrapped evenly around the arm can
result in a false high blood pressure reading.
What should the nurse do if the patient's blood pressure is not within normal limits?
A. Review the blood pressure readings in the patient's record.
B. Assess for proper cuff size and arm positioning.
C. Promptly report the assessment data to the nurse in charge or to the health care
provider.
D. Encourage the patient to rest quietly in bed for 30 minutes, and then retake the
blood pressure. - Answer-C. Promptly report the assessment data to the nurse in
charge or to the health care provider.
Rationale: Promptly reporting the assessment data to the nurse in charge is the
correct response, because the patient must be assessed for possible cardiovascular
problems. Reviewing the blood pressure readings in the patient's record is not the
correct response, because a blood pressure reading outside of normal limits must be
reported without delay to the nurse in charge or to the health care provider. The
nurse would have assessed for proper cuff size and positioned the arm correctly
before measuring the blood pressure. Encouraging the patient to rest quietly in bed
for 30 minutes, and then retake the blood pressure is not the correct response. A
blood pressure reading outside of normal limits must be reported without delay to the
nurse in charge or to the health care provider.
What would the nurse do to prevent the spread of infection when assessing a
patient's blood pressure?
A. Wear gloves.
B. Avoid using an arm in which an intravenous catheter has been inserted.
C. Clean the stethoscope with alcohol before and after using it.
D. Inflate the cuff 30 mm higher than the expected systolic pressure. - Answer-C.
Clean the stethoscope with alcohol before and after using it.
