1. The nurse is caring for a patient with chronic lower back pain. The nurse
knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
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133
,The patient's heart rate is 90 beats per minute.: A
2. Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level.: B
The patient's arm should be supported at heart level. Separate BP readings may
need to be taken, but not one right after the other. The length of the BP bladder
should equal 80% of the arm circumferen
3. The nurse obtains which piece of data during the general survey?
Client is alert and calm.
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133
,Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
Client's lung sounds are "clear" to auscultation.: A
4. A man is at the clinic for a complete physical exam. He states that he is "very
anxious". What steps can the nurse take to make him more comfortable?
Appear confident and unhurried during the exam.
Measure vital signs at the end to allow the patient sufficient time to relax.
3/
133
, Let him leave his clothes on during the examination.
Obtain another nurse to examine the patient.: A
5. A father brings his 13 month-old child in for "fever" and he reports that the
child has been "pulling on his left ear". Upon entering the exam room, the child
is asleep in the father's arms. The nurse should perform which assessment
first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and nose.
Auscultate the lungs, heart, and abdomen.
Assess gross motor skills using the Denver II screening tool.: C
6. An 18 year-old presents to the emergency department with "headache."
Which of these assessment findings alerts the nurse to recent opioid use?
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knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
1/
133
,The patient's heart rate is 90 beats per minute.: A
2. Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level.: B
The patient's arm should be supported at heart level. Separate BP readings may
need to be taken, but not one right after the other. The length of the BP bladder
should equal 80% of the arm circumferen
3. The nurse obtains which piece of data during the general survey?
Client is alert and calm.
2/
133
,Client's heart rate is 80 beats per minute.
Client's body mass index (BMI) is 30.
Client's lung sounds are "clear" to auscultation.: A
4. A man is at the clinic for a complete physical exam. He states that he is "very
anxious". What steps can the nurse take to make him more comfortable?
Appear confident and unhurried during the exam.
Measure vital signs at the end to allow the patient sufficient time to relax.
3/
133
, Let him leave his clothes on during the examination.
Obtain another nurse to examine the patient.: A
5. A father brings his 13 month-old child in for "fever" and he reports that the
child has been "pulling on his left ear". Upon entering the exam room, the child
is asleep in the father's arms. The nurse should perform which assessment
first?
Use the otoscope to look inside the ear.
Use a penlight to check the eyes and nose.
Auscultate the lungs, heart, and abdomen.
Assess gross motor skills using the Denver II screening tool.: C
6. An 18 year-old presents to the emergency department with "headache."
Which of these assessment findings alerts the nurse to recent opioid use?
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133
