Fundamentals Final Reviewer Test bank - Questions and Answers Vital Signs

Fundamentals Final Reviewer Test bank - Questions and Answers Vital Signs Fundamentals Final Reviewer Test bank - Questions and Answers Vital Signs MULTIPLE CHOICE 1. A nurse notes a patient has abnormal vital signs. What action by the nurse is best? 2. A patient returned from a procedure and has vital sign measurements ordered every hour. The patient’s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate? 3. A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement? 4. A nurse is caring for a patient who has a high temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use? 5. A nurse is going to take a patient’s oral temperature. The patient has been drinking coffee. What action by the nurse is best? 6. A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene? 7. A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? 8. The student nurse is assessing a patient’s pulses. What action by the student requires the nurse to intervene? 9. The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action by the nurse is best? c. Compare with prior readings. Plan to take the vital signs more often. d. b. Temperature 98.4° F (36.8° C) b. Putting ice packs in the patient’s axillae b. Return in 30 minutes to take the patient’s temperature. b. Student pulls the pinna of the patient’s ear down and back a. Assess the patient for causes of tachycardia. b. Assessing the doralis pedis pulse by palpating behind the patient’s knee Assess the patient for fluid volume overload. a. 10. The nursing faculty member is observing a student taking a patient’s carotid pulse. What action by the student requires intervention by the faculty member? 11. A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate? 12. The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? 13. A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure? 14. A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best? 15. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? 16. A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best? 17. The nurse receives a handoff report on four patients. Which patient should the nurse assess first? 18. A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient’s respiratory rate is so high. What response by the nurse is best? 1. The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.) c. Compares pulses in both carotid arteries at the same time. c. Keep the head of the bed elevated. Assess the fingers for good circulation. b. d. 66 a. Instruct the patient not to get up without help. Place a sign above the bed: “No blood pressures on the right arm.” a. Ask the patient to rate and describe the pain. b. Pulse 42 beats/min c. “The lungs are trying to rid the body of b. extra carbon dioxide.” a. b. Monitor body systems functioning. Identify early signs of problems. Evaluate effectiveness of interventions. c. Provide a baseline to compare against. e. ANS: A, B, C, E 2. The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.) 3. The nurse understands that which factors can increase blood pressure? (Select all that apply.) 4. The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.) 5. A nurse is teaching a patient and the patient’s family about self-care measures for hypertension. Which topics does the nurse include? (Select all that apply.) 6. Which parameters does the nurse include when assessing pain? (Select all that apply.) “Take Mrs. Jones’ blood pressure every 15 minutes.” b. “Call me if Ms. Walsh’s systolic blood pressure drops to under 100 mm Hg.” c. “Do you want me to demonstrate using the electronic blood pressure cuff?” d. e. “I’ll take Mr. Derby’s blood pressure since he is not stable.” a. Head injury Increasing age c. d. Recent food intake e. Pain a. Brain b. Lungs c. Heart b. Maintain a normal body weight d. Reduce dietary sodium to 2.4 g/day e. Follow the DASH diet a. Facial expression c. Shallow respirations d. Immobility 7. A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.) a. Agitation Restlessness b. Vital signs d. Health History and Physical Assessment 1. A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate? 2. A patient wishes to review his medical record. What response by the nurse is best? 3. A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best? 4.A student nurse is preparing to auscultate a patient’s lungs. What action by the student leads the instructor to intervene? 5. The nurse is assessing a patient’s alcohol intake. What question is most appropriate? 6. The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education? 7. A nurse has assessed a patient’s capillary refill, which was 5 seconds. What action by the nurse is most appropriate? Provide a method for ensuring the patient stays warm. b. “Yes, I can sit with you while you look at it so you can ask questions.” c. Call for another staff member to bring the equipment. b. Student uses the stethoscope bell to listen to bowel sounds. c. “How much alcohol do you drink daily?” d. Adolescent who uses a tanning bed a. Assess the patient for signs of hypoxia. d. 8. The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best? 9. A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over- the-bed table. What action by the nurse is best? and Maintenance NOT: Concepts: Gas Exchange 10. The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best in order to hear the murmur? 11. A nurse has conducted an Allen’s test on a patient and the result was 8 seconds. What action by the nurse is best? 12. A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best? 13. A nurse is told in handoff report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient’s Glasgow Coma Scale to be? 14. A nurse is assessing a patient’s abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best? 15. A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best? 16. A nurse assesses a patient’s lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best? 17. The nurse is assessing a patient’s cranial nerve III. What technique is best? Healthy eye first to prevent spread of disease b. Assess the patient for a barrel-chest appearance. a. Auscultate the patient’s chest with a stethoscope. c. a. Document the findings and continue the assessment. d. Educate the patient on why a massage would be contraindicated. d. 13 b. Document the findings in the patient’s chart. a. Get the provider; assist patient into lithotomy position. b. Prepare to treat the patient for pneumonia. b. Shine a light into the patient’s eyes to assess pupil response. 18. A nurse is assessing a patient’s cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best? 19. The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate? 1. A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process? (Select all that apply.) 2. A nurse is conducting a physical examination using palpation. Which assessments might the nurse note? (Select all that apply.) 3. A nurse conducting the general survey of a patient includes which items? (Select all that apply.) 4. The nurse examining a patient’s skin correlates which conditions with which underlying pathology? (Select all that apply.) 5. A nurse is educating women on breast cancer risk reduction. What topics does the nurse include in the presentation? (Select all that apply.) Ask the patient about recent facial trauma. a. Inspect the patient’s nails and surrounding skin. c. Typing intently on a keyboard when asking questions. a. Providing non-verbal cues to negative thoughts. e. Crepitation: crackling or rubbing b. Turgor: tension caused by fluid content d. Consistency: organ location and size e. a. Hygiene and grooming b. Affect and mood c. Sex and gender orientation e. Age b. Peripheral cyanosis: poor circulation c. Purpura: clotting disorders d. Jaundice: liver disease a. Exercise Limiting alcohol b. Low-fat diet c. 6. A nurse has finished examining a patient. What actions does the nurse take next? (Select all that apply.) Urinary Elimination 1. The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. Which type of renal failure did the patient most likely develop? 2. The nurse is caring for a patient with diabetes insipidus. The patient has constant severe thirst, drinks fluids continuously, and voids 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient’s urinary output? 3. The nurse is caring for a patient who is experiencing stress incontinence. Which goal is the most important for this patient? 4. The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse? 5. The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient? 6. The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine on the toilet. Which is the priority assessment to be performed by the nurse? Document all findings. a. Provide privacy for dressing. b. c. Provide any hygiene material needed. Cleans the room after the patient leaves. e. Prerenal a. Polyuria c. The patient will not experience involuntary urination during coughing or sneezing. b. d. Obtain an order to straight-catheterize the patient. c. Knowledge deficit related to care and maintenance of ostomy appliance