Question | ( po
mnt)
Ifa 52-year-old
patient has a no rmal
temperature fal wi temperature, what range should the
hin? patient's
AD36-38°C
B) 37-39°c
C) 35.36¢
D) 36-37C
Question 2 (I poin
t)
When 2 ing thethe respiratory
»th assessing res =
rate, the nurse has difficulty
with inspiration and expiration. seeing the patient’s chest rise and fall
What is the nurse’s best action?
A) Have someone el ¢ assess
the patient’s respiratory rate.
B) Remove the patient’s gown so
you have better visualization of the patient’s chest for
assessment.
@ ile holding the patient's wrist, move the patient’ arm
the: n feel the rise and fall of inspirati and s over the chest or abdomen, and
on expiration and assess the rate.
D) Document the inability to visual
ize inspiration and expiration,
Question 3 (1 point)
Who would the nurse expect to have the high
est body temperature reading?
% An adult female who is walking
A teenager playing video games
C) Anolder male
Question 4(1 point)
In which of the following patients would the nurse expect
to find a decrease in
pulse rate? (Select all that apply)
A patient returning from the operating room after having a hip replacement
@DA patient who received morphine for severe cancer pain
C) A student who is getting ready to take a final exam
D) A patient who had a bleding episode
Question 5 (1 point)
Which pulse site is correctly identified with it's location?
A) Radial posterior side of wrist
#® Brachial medial aspect of the antecubital fossa
C) carotid - midclavicular line, Sth intercostal space
D) posterior tibial behind the knee
Question 6 (1 point)
Which ofthe following patients would be at risk for having an alteration in
peripheral pulse? (Select all that apply.)
‘A) A 76-year-old with Type 1 diabetes who is otherwise healthy
A patient who was just informed ofa diagnosis of cancer
A patient with peripheral vascular disease
§ A patient who is receiving bolus IV fluids
E) A patient with Alzheimer's disease
, ———
Question 7 (1 point)
The nurse is going to assess an adult patient's apical pulse at the point of maximal
mpulse (PMI). Where will the nurse place the stethoscope?
A) Fourth intercostal space. right midclavicular line.
B) Fifth intercostal space, right midclavicular line
) Fifth intercostal space, left midclavicular line.
Fourth intercostal space, left midclavicular line.
Question 8(1 point)
Patients with apnea Experience:
A) Slowness of breathing followed by rapid breath
ing
B) difficult respirations that require more effort
©) lack of oxygen to body tissues and organs
t@ Cessation of breathing that may be tempor
ary
Question 9 (1 point)
1f the nurse suspects the NG feeding tube has migra
ted, which of the following
should the nurse do?
A) Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the tube.
B) Repmiliun the patient from side to side.
C) Trrigate the tube with tap water.
e placement.
@) Stop any enteral feedings and obtain an order for a chest X-ray to determin
Question 10 (1 point)
A nurse measures a client's 24 hour intake & output. To determine the fluid balance. what must the
nurse do with the information?
%A) assess the abdomen for signs and symptoms of retention
Compare the client’s intake in 24 hours with the normal range of adult intake
#C) calculate the average hourly output and multiply by 24
Q subtract the total output from the total intake for a 24 hour period
Question 11 (1 point)
Which of the following is a possible sign of dysphagia?
A) Lack of taste
B) 5-35 bowel sounds per minute
C) Hypersensitivity to foods
Coughing after swallowing
Question 12 (1 point)
Michael, 18 years old, is admitted to your unit after an emergency appendectomy
The physician orders a clear fluid diet. Which of the following would be the most appropriate?
) milk
Ginger age
C) cola
D) Cream of mushroom soup
Question 13 (1 point
The nurse suspects that the patient’s feeding tube has migrated. Which of the
mnt)
Ifa 52-year-old
patient has a no rmal
temperature fal wi temperature, what range should the
hin? patient's
AD36-38°C
B) 37-39°c
C) 35.36¢
D) 36-37C
Question 2 (I poin
t)
When 2 ing thethe respiratory
»th assessing res =
rate, the nurse has difficulty
with inspiration and expiration. seeing the patient’s chest rise and fall
What is the nurse’s best action?
A) Have someone el ¢ assess
the patient’s respiratory rate.
B) Remove the patient’s gown so
you have better visualization of the patient’s chest for
assessment.
@ ile holding the patient's wrist, move the patient’ arm
the: n feel the rise and fall of inspirati and s over the chest or abdomen, and
on expiration and assess the rate.
D) Document the inability to visual
ize inspiration and expiration,
Question 3 (1 point)
Who would the nurse expect to have the high
est body temperature reading?
% An adult female who is walking
A teenager playing video games
C) Anolder male
Question 4(1 point)
In which of the following patients would the nurse expect
to find a decrease in
pulse rate? (Select all that apply)
A patient returning from the operating room after having a hip replacement
@DA patient who received morphine for severe cancer pain
C) A student who is getting ready to take a final exam
D) A patient who had a bleding episode
Question 5 (1 point)
Which pulse site is correctly identified with it's location?
A) Radial posterior side of wrist
#® Brachial medial aspect of the antecubital fossa
C) carotid - midclavicular line, Sth intercostal space
D) posterior tibial behind the knee
Question 6 (1 point)
Which ofthe following patients would be at risk for having an alteration in
peripheral pulse? (Select all that apply.)
‘A) A 76-year-old with Type 1 diabetes who is otherwise healthy
A patient who was just informed ofa diagnosis of cancer
A patient with peripheral vascular disease
§ A patient who is receiving bolus IV fluids
E) A patient with Alzheimer's disease
, ———
Question 7 (1 point)
The nurse is going to assess an adult patient's apical pulse at the point of maximal
mpulse (PMI). Where will the nurse place the stethoscope?
A) Fourth intercostal space. right midclavicular line.
B) Fifth intercostal space, right midclavicular line
) Fifth intercostal space, left midclavicular line.
Fourth intercostal space, left midclavicular line.
Question 8(1 point)
Patients with apnea Experience:
A) Slowness of breathing followed by rapid breath
ing
B) difficult respirations that require more effort
©) lack of oxygen to body tissues and organs
t@ Cessation of breathing that may be tempor
ary
Question 9 (1 point)
1f the nurse suspects the NG feeding tube has migra
ted, which of the following
should the nurse do?
A) Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the tube.
B) Repmiliun the patient from side to side.
C) Trrigate the tube with tap water.
e placement.
@) Stop any enteral feedings and obtain an order for a chest X-ray to determin
Question 10 (1 point)
A nurse measures a client's 24 hour intake & output. To determine the fluid balance. what must the
nurse do with the information?
%A) assess the abdomen for signs and symptoms of retention
Compare the client’s intake in 24 hours with the normal range of adult intake
#C) calculate the average hourly output and multiply by 24
Q subtract the total output from the total intake for a 24 hour period
Question 11 (1 point)
Which of the following is a possible sign of dysphagia?
A) Lack of taste
B) 5-35 bowel sounds per minute
C) Hypersensitivity to foods
Coughing after swallowing
Question 12 (1 point)
Michael, 18 years old, is admitted to your unit after an emergency appendectomy
The physician orders a clear fluid diet. Which of the following would be the most appropriate?
) milk
Ginger age
C) cola
D) Cream of mushroom soup
Question 13 (1 point
The nurse suspects that the patient’s feeding tube has migrated. Which of the
