Health Assessment Elsevier Test
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1. What is the primary purpose of initially assessing an apical pulse?
A. Assessment of the patient's cardiac function
B. Establishment of a baseline as part of the patient's vital signs
C. Assessment of the patient's risk for cardiovascular disease
D. Determination of oxygen saturation: B. Establishment of a baseline as part of the patient's vital
signs
2. What instruction should the nurse give nursing assistive personnel (NAP)
regarding the appropriate technique when measuring the adult patient's apical
pulse?
A. Document the patient's pulse rate and rhythm
B. Place the patient in the right lateral position before measuring the apical
pulse
C. Review the patient's previous apical pulse measurements
D. Place your stethoscope at the fifth intercostal space over the left midclavic-
ular line: D. Place your stethoscope at the fifth intercostal space over the left midclavicular line
3. Which action would take priority if a patient's apical pulse has an irregular
rhythm?
A. Reassess the pulse for 1 full minute
B. Assess the patient's peripheral pulses
C. Wait 5 minutes, and then reassess the apical pulse
D. Review documentation regarding an irregular rhythm: A. Reassess the pulse for 1 full
minute
4. Which statement demonstrates an understanding of the importance of com-
municating changes in the patient's apical pulse rate?
A. "The patient's apical pulse is recorded as you asked."
B. "The apical pulse is more difficult to hear when the patient is sitting up."
C. "The apical pulse is usually slower in the morning that is is in the afternoon."
D. "The apical pulse increased from 78 to 110, but the patient had just returned
from the bathroom.": D. "The apical pulse increased from 78 to 110, but the patient had just returned from
the bathroom."
5. The nurse can best determine the effect of crying on a patient's apical pulse
by doing what?
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A. Measuring the patient's apical pulse before and after crying
B. Assessing the patient's apical pulse 30 minutes after crying
C. Measuring the patient's pulse deficit after crying
D. Comparing the patient's post-crying apical pulse rate with her baseline or
previous rate: D. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate
6. What is the major health problem resulting from a pulse deficit?
A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion: C. Decreased cardiac output
7. What should the nurse do when a pulse deficit is suspected?
A. Measure the radial pulse for 1 min, and then measure the apical pulse for 1
min
B. Measure the radial pulse for 30 seconds, and then measure the apical for 30
seconds
C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the
apical pulse for 1 minute
D. Ask another health care provider to count the radial pulse while the nurse
counts the apical pulse: D. Ask another health care provider to count the radial pulse while the nurse counts
the apical pulse
8. Which action should the nurse perform after identifying a pulse deficit?
A. Reassess the apical-radical pulse in 5 minutes
B. Assess the patient for signs of decreased cardiac output
C. Notify the primary health care provider of the pulse deficit
D. Initiate interventions directed toward managing the patient's symtoms: B.
Assess the patient for signs of decreased cardiac output
9. You have the following information:
Radial Pulse- 112 weak, thready
Apical Pulse- 117 regular
What is the pulse deficit?
A. 2
B. 5
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C. 6
D. 48: B. 5
10. Which of the following is an early manifestation of decreased cardiac out-
put?
A. Fatigue
B. Substernal Pain
C. Nail bed cyanosis
D. Shortness of breath: A. Fatigue
11. What will the nurse instruct nursing assistive personnel to when measuring
a patient's rectal temperature using an electronic thermometer?
A. Place the patient in the Fowler's position
B. Wear sterile gloves during the process
C. Insert the probe in the direction of the knees.
D. use the probe with the red tip: D. Use the probe with the red tip
12. Which of the following is contraindicated with taking a rectal temperature
measurement?
A. Patient requires assistance to move to a side-lying position
B. Patient has painful and swollen hemorrhoids
C. Patient is incontinent of urine
D. The last temperature recorded was 0.2 F above baseline: B. Patient has painful and
swollen hemorrhoids
13. Which nursing action best evaluates the effectiveness of an antipyretic med-
ication in a patient with an oral temperature of 101.6 F?
A. Assess for physical aches
B. Assess skin temperature by touching the forehead
C. Assess oral temperature 30 minutes after the agent is administered
D. Assess skin color for signs of fever-related flushing: C. Assess oral temperature 30 minutes
after the agent is adminstered
14. Which instruction might the nurse give to nursing assistant that is applicable
only to tympanic temperature assessment?
A. Leave the probe in place until the reading is complete
B. Put on a new disposable probe cover for each patient
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C. Gently tug the pinna backward, up, and out before inserting the probe
D. Check for any impact cerumen in the ear: C. Gently tug the pinna backward, up, and out before
inserting the probe
15. Which instruction might the nurse give nursing assistant that is applicable
only to temporal artery temperature assessment?
A. An accurate temperature reading is obtained with moisture on the forehead
B. Put on a disposable sensor cover before taking the temporal artery temper-
ature
C. Place the sensor flush on the patient's forehead
D. Obtain the temperature reading on the lower neck: C. Place the sensor flush on the
patient's forehead
16. During the admissions process, the nurse initially assesses the patient's
radial pulse primarily for what purpose?
A. Assessment of peripheral blood perfusion
B. Establishment of a baseline as part of the patient's vital signs
C. Assessment of the patient's cardiovascular disease risk
D. Determination of oxygen saturation: B. Establishment of a baseline as part of the patient's vital
signs
17. What will the nurse instruct nursing assistant to do when measuring an
adult's radial pulse?
A. Place the patient in lateral (side-lying) position before measuring the pulse
B. Apply gloves with each patient before measuring the pulse
C. Document whether the patient's pulse is bounding or has diminished
D. Palpate the patient's inner wrist on the thumb side with the fingertips of
your two middle fingers: D. Palpate the patient's inner wrist on the thumb side with the fingertips of your
two middle fingers
18. What is the nurse's priority action if a patient's radial pulse has an irregular
rhythm?
A. Reassess the pulse for 1 full minute
B. Assess the patient for a pulse deficit
C. Wait 5 minutes, and then reassess the pulse
Study online at https://quizlet.com/_i1dpjt
1. What is the primary purpose of initially assessing an apical pulse?
A. Assessment of the patient's cardiac function
B. Establishment of a baseline as part of the patient's vital signs
C. Assessment of the patient's risk for cardiovascular disease
D. Determination of oxygen saturation: B. Establishment of a baseline as part of the patient's vital
signs
2. What instruction should the nurse give nursing assistive personnel (NAP)
regarding the appropriate technique when measuring the adult patient's apical
pulse?
A. Document the patient's pulse rate and rhythm
B. Place the patient in the right lateral position before measuring the apical
pulse
C. Review the patient's previous apical pulse measurements
D. Place your stethoscope at the fifth intercostal space over the left midclavic-
ular line: D. Place your stethoscope at the fifth intercostal space over the left midclavicular line
3. Which action would take priority if a patient's apical pulse has an irregular
rhythm?
A. Reassess the pulse for 1 full minute
B. Assess the patient's peripheral pulses
C. Wait 5 minutes, and then reassess the apical pulse
D. Review documentation regarding an irregular rhythm: A. Reassess the pulse for 1 full
minute
4. Which statement demonstrates an understanding of the importance of com-
municating changes in the patient's apical pulse rate?
A. "The patient's apical pulse is recorded as you asked."
B. "The apical pulse is more difficult to hear when the patient is sitting up."
C. "The apical pulse is usually slower in the morning that is is in the afternoon."
D. "The apical pulse increased from 78 to 110, but the patient had just returned
from the bathroom.": D. "The apical pulse increased from 78 to 110, but the patient had just returned from
the bathroom."
5. The nurse can best determine the effect of crying on a patient's apical pulse
by doing what?
, Health Assessment Elsevier Test
Study online at https://quizlet.com/_i1dpjt
A. Measuring the patient's apical pulse before and after crying
B. Assessing the patient's apical pulse 30 minutes after crying
C. Measuring the patient's pulse deficit after crying
D. Comparing the patient's post-crying apical pulse rate with her baseline or
previous rate: D. Comparing the patient's post-crying apical pulse rate with her baseline or previous rate
6. What is the major health problem resulting from a pulse deficit?
A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion: C. Decreased cardiac output
7. What should the nurse do when a pulse deficit is suspected?
A. Measure the radial pulse for 1 min, and then measure the apical pulse for 1
min
B. Measure the radial pulse for 30 seconds, and then measure the apical for 30
seconds
C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the
apical pulse for 1 minute
D. Ask another health care provider to count the radial pulse while the nurse
counts the apical pulse: D. Ask another health care provider to count the radial pulse while the nurse counts
the apical pulse
8. Which action should the nurse perform after identifying a pulse deficit?
A. Reassess the apical-radical pulse in 5 minutes
B. Assess the patient for signs of decreased cardiac output
C. Notify the primary health care provider of the pulse deficit
D. Initiate interventions directed toward managing the patient's symtoms: B.
Assess the patient for signs of decreased cardiac output
9. You have the following information:
Radial Pulse- 112 weak, thready
Apical Pulse- 117 regular
What is the pulse deficit?
A. 2
B. 5
, Health Assessment Elsevier Test
Study online at https://quizlet.com/_i1dpjt
C. 6
D. 48: B. 5
10. Which of the following is an early manifestation of decreased cardiac out-
put?
A. Fatigue
B. Substernal Pain
C. Nail bed cyanosis
D. Shortness of breath: A. Fatigue
11. What will the nurse instruct nursing assistive personnel to when measuring
a patient's rectal temperature using an electronic thermometer?
A. Place the patient in the Fowler's position
B. Wear sterile gloves during the process
C. Insert the probe in the direction of the knees.
D. use the probe with the red tip: D. Use the probe with the red tip
12. Which of the following is contraindicated with taking a rectal temperature
measurement?
A. Patient requires assistance to move to a side-lying position
B. Patient has painful and swollen hemorrhoids
C. Patient is incontinent of urine
D. The last temperature recorded was 0.2 F above baseline: B. Patient has painful and
swollen hemorrhoids
13. Which nursing action best evaluates the effectiveness of an antipyretic med-
ication in a patient with an oral temperature of 101.6 F?
A. Assess for physical aches
B. Assess skin temperature by touching the forehead
C. Assess oral temperature 30 minutes after the agent is administered
D. Assess skin color for signs of fever-related flushing: C. Assess oral temperature 30 minutes
after the agent is adminstered
14. Which instruction might the nurse give to nursing assistant that is applicable
only to tympanic temperature assessment?
A. Leave the probe in place until the reading is complete
B. Put on a new disposable probe cover for each patient
, Health Assessment Elsevier Test
Study online at https://quizlet.com/_i1dpjt
C. Gently tug the pinna backward, up, and out before inserting the probe
D. Check for any impact cerumen in the ear: C. Gently tug the pinna backward, up, and out before
inserting the probe
15. Which instruction might the nurse give nursing assistant that is applicable
only to temporal artery temperature assessment?
A. An accurate temperature reading is obtained with moisture on the forehead
B. Put on a disposable sensor cover before taking the temporal artery temper-
ature
C. Place the sensor flush on the patient's forehead
D. Obtain the temperature reading on the lower neck: C. Place the sensor flush on the
patient's forehead
16. During the admissions process, the nurse initially assesses the patient's
radial pulse primarily for what purpose?
A. Assessment of peripheral blood perfusion
B. Establishment of a baseline as part of the patient's vital signs
C. Assessment of the patient's cardiovascular disease risk
D. Determination of oxygen saturation: B. Establishment of a baseline as part of the patient's vital
signs
17. What will the nurse instruct nursing assistant to do when measuring an
adult's radial pulse?
A. Place the patient in lateral (side-lying) position before measuring the pulse
B. Apply gloves with each patient before measuring the pulse
C. Document whether the patient's pulse is bounding or has diminished
D. Palpate the patient's inner wrist on the thumb side with the fingertips of
your two middle fingers: D. Palpate the patient's inner wrist on the thumb side with the fingertips of your
two middle fingers
18. What is the nurse's priority action if a patient's radial pulse has an irregular
rhythm?
A. Reassess the pulse for 1 full minute
B. Assess the patient for a pulse deficit
C. Wait 5 minutes, and then reassess the pulse
