Answers 100% Accurate 2025
Which assessment by the nurse most likely indicates that a patient is having difficulty
breathing?
a. 18 breaths per minute and inhaled through the mouth
b. 20 breathes per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy --Correct Answer--d. 28 breaths per minute and noisy
Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer.
b. Position the patient on the left side.
c. Use an electronic thermometer.
d. Lubricate the thermometer. --Correct Answer--d. Lubricate the thermometer.
A nurse is assessing a patient's ideal body weight. Which significant factor should be takin
into consideration when performing this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preferences --Correct Answer--b. Body height
A nurse asks a patient's wife specific questions about the patient's health status before
admission. When collecting this information, the nurse is seeking information from a:
a. Primary source
b. Tertiary sources
c. Subjective source
d. Secondary source --Correct Answer--d. Secondary source
A nurse is preforming a physical assessment of a newly admitted patient. Which patient
statement communicates subjective data?
a. "I have sores between my toes."
b. "I dye my hair but it is really gray."
, c. "My joints hurt when I get up in the morning."
d. "My left leg drags on the floor when I am walking." --Correct Answer--c. "My joints hurt
when I get up in the morning."
A nurse takes a patient's blood pressure and records a diastolic pressure of 120 mm Hg.
Which should the nurse do first?
a. Notify the primary health-care provider.
b. Retake the blood pressure.
c. Notify the nurse in charge.
d. Take the other vital signs --Correct Answer--b. Retake the blood pressure.
A patient who experienced a stroke has left-sided hemiparesis and is incontinent of urine.
Which is an appropriately worded nursing diagnosis for this patient?
a. The patient has a need to maintain skin integrity.
b. The patient has a stroked evidenced by hemiparesis and incontinence.
c. The patient will be clean and dry and will receive range-of-motion exercises every four
hours.
d. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and
incontinence --Correct Answer--d. The patient is at risk for impaired skin integrity related to
left-sided hemiparesis and incontinence
A patient had a stroke that resulted in paralysis of the right side. When clustering data, the
nurse grouped the following together: drooling of saliva and slurred speech. Which
information is most significant to include with this clustered data?
a. Receptive aphasia
b. Inability to ambulate
c. Difficulty swallowing
d. Incontinence of bowel movements --Correct Answer--c. Difficulty swallowing
A nurse uses the interviewing process of clarification when interviewing a patient. Which is
the nurse doing when this communication technique is used? a. Paraphrasing the patient's
message
b. Restating what the patient has said
c. Reviewing the patient's communication
d. Verifying what is implied by the patient --Correct Answer--d. Verifying what isimplied by
the patient