COMPLETE SOLUTIONS
A 48-year-old patient comes to the physicians
office complaining of diminished near vision, which
The nurse confirms with testing. She should
document this finding as:
1. Myopia
2. Diplopia
3. Presbyopia
4. Mydriasis Correct Answers 3. Presbyopia
A 78-year-old patient is being seen in the
emergency department. The nurse observes his
gait and balance appear to be slightly unsteady
what assessment should the nurse perform next?
1. Perform to get up and go test
2. Ask the patient if he has fallen in the past year
3. Refer the patient for a comprehensive fall
evaluation
4. Administer the timed up and go test Correct
Answers Ask the patient if he has fallen in the past
year
A child is brought to the emergency department
after swallowing liquid cleanser. He is awake and
alert and able to swallow. Which action should the
nurse take first?
1. Administer a dose of syrup of ipecac
2. Administer activated charcoal immediately
,3. Give water to the child immediately
4. Call the nearest poison control center Correct
Answers Give water to the child immediately
A client who has been hospitalized for an infection
states the nursing assistant told me my vital signs
are all within normal limits that means I'm cured.
The nurses best response would be which of the
following?
1. Your vital signs confirm that your infection is
resolved. How do you feel?
2. I'll let your Health care provider know so you can
be discharged
3. Your vital signs are stable but there are other
things to assess
4. We still need to keep monitoring your
temperature for a while Correct Answers 3. Your
vital signs are stable but there are other things to
assess
A client's vital signs at the beginning of the shift
are as follows: oral temperature 99.3°F (37°C),
heart rate 82 beats per minute, respiratory rate 14
breaths per minute, and blood pressure 118/76.
Four hours later the client's oral temperature is
102.2°F (39°C). Based on the temperature change,
the nurse should anticipate the client's heart rate
would be how many beats per minute?
1. 62
2. 82
,3. 102
4. 122 Correct Answers 3. 102
A clients average normal temperature is 98°F.
Which of the following temperatures would be
expected during the night in this healthy young
adult client who does not have a fever,
inflammatory process, or underlying health
problem
1. 97.2F
2. 98F
3. 98.6F
4. 99.2F Correct Answers 1. 97.2F
A clients axillary temperature is 100.8°F. The
nurses realize this is outside normal range for this
client and that axillary temperatures do not reflect
core temperature. What should the nurse is due to
obtain a good estimate of the core temperature?
1. Add 1°F to 100.8°F to obtain an oral equivalent
2. Add 2°F to 100.8°F to obtain a rectal equivalent
3. Obtain a rectal temperature reading
4. Obtain a tympanic membrane reading Correct
Answers 3. Obtain a rectal temperature rating
A clients vital signs 4 hours ago were temperature
(oral) 101.4F, heart rate 110/min, respiratory rate
26/min, and blood pressure 124/78 mm Hg. The
temperature is now 99.4F. Based only on the
expected relationship between temperature and
, respiratory rate, the nurse might best anticipate
the clients respiratory rate to be
1. 16
2. 18
3. 20
4. 22 Correct Answers 2. 18
A father brings his 18 month old child to the
pediatric clinic for a while baby check up. The
father tells the nurse that he was concerned
because it's child's legs are bowed. Which
response by the nurse is appropriate?
1. Your child will most likely require physical
therapy
2. You should consider having your child seen by
an orthopedic surgeon
3. This is a normal finding and children for one year
after they've been walking
4. Your child is walking fine, so you don't need to
worry Correct Answers 3. This is a normal finding
in children for one year after they begin walking
A female patient has excessive facial hair. The
nurse to document this finding as:
1. Alopecia
2. Albinism
3.Hirsutism
4. Lanugo Correct Answers 3. Hirsutism