3ucslion 1(1
0 U::;,::?‘i poin t)
a52-y fi rxlll:;;::?hm anorma
ati l temperature, what
range should (he pa
tient's
-@36—38°C
B) 37-39°C
C) 35-36C
D) 36-37C
Question 2 (] poi
nt)
When assecc;
"l ;n -L‘\S.cs et
svmg the respira tory rate, the nurse has dif;i ficulty seeing
with inspiration and expiration. What the patient's chest rise and fall
is the nurse's best action?
A) Have someone else assess the patie
nt's respiratory rate.
B) Remove the patient’s gown so you have
better visualization of the patient's chest for
~.assessment.
@Mile holding the patient’s wrist, move
the patient’s arm over the chest or abdomen,
then feel the rise and fall of inspiration and expir and
ation and assess the rate.
D) Document the inability to visualize
inspiration and expiration,
Question 3 (1 point)
Who would the nurse expect to have the highe
st body temperature reading?
A) An adult female who is walking
A teenager playing video games
C) An older male
Question 4(1 point)
In which of the following patients would the nurse expect
o find a decrease in
pulse rate? (Select all that apply)
A patient returning from the operating room after having a hip replacement
B A 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, 5th intercostal space
D) posterior tibial behind the knee
Question 6 (1 point)
Which of the following patients would be at risk for having an alteration in
peripheral pulse? (Select all that apply.)
A) A 76-year-old with Type | diabetes who is otherwise healthy
@ A patient who was just informed of a 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
impulse (PMI). Where will the nurse place the stethoscope?
A) Fourth intercostal space. right midclavicular line.
B) Fifth intercostal space, right midclavicular line.
C) JFifth 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 breathin
g
B) difficult respirations that require more effort
C) lack of oxygen to body tissues and orga
ns
/@ Cessation of breathing that may be temporar
y
Question 9 (1 point)
If the nurse suspects the NG feeding tube has migrated, which of the following
should the nurse do?
A) Insill 10 mL of water into the feeding tbe, reinsert the stylet, and reposition the tube.
B) RePOSIliOn the patient from side to side.
C) Irrigate the tube with tap water.
(DY Stop any enteral feedings and obtain an order for a chest X-ray to determine placement.
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?
Yfi 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 afier 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
0 U::;,::?‘i poin t)
a52-y fi rxlll:;;::?hm anorma
ati l temperature, what
range should (he pa
tient's
-@36—38°C
B) 37-39°C
C) 35-36C
D) 36-37C
Question 2 (] poi
nt)
When assecc;
"l ;n -L‘\S.cs et
svmg the respira tory rate, the nurse has dif;i ficulty seeing
with inspiration and expiration. What the patient's chest rise and fall
is the nurse's best action?
A) Have someone else assess the patie
nt's respiratory rate.
B) Remove the patient’s gown so you have
better visualization of the patient's chest for
~.assessment.
@Mile holding the patient’s wrist, move
the patient’s arm over the chest or abdomen,
then feel the rise and fall of inspiration and expir and
ation and assess the rate.
D) Document the inability to visualize
inspiration and expiration,
Question 3 (1 point)
Who would the nurse expect to have the highe
st body temperature reading?
A) An adult female who is walking
A teenager playing video games
C) An older male
Question 4(1 point)
In which of the following patients would the nurse expect
o find a decrease in
pulse rate? (Select all that apply)
A patient returning from the operating room after having a hip replacement
B A 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, 5th intercostal space
D) posterior tibial behind the knee
Question 6 (1 point)
Which of the following patients would be at risk for having an alteration in
peripheral pulse? (Select all that apply.)
A) A 76-year-old with Type | diabetes who is otherwise healthy
@ A patient who was just informed of a 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
impulse (PMI). Where will the nurse place the stethoscope?
A) Fourth intercostal space. right midclavicular line.
B) Fifth intercostal space, right midclavicular line.
C) JFifth 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 breathin
g
B) difficult respirations that require more effort
C) lack of oxygen to body tissues and orga
ns
/@ Cessation of breathing that may be temporar
y
Question 9 (1 point)
If the nurse suspects the NG feeding tube has migrated, which of the following
should the nurse do?
A) Insill 10 mL of water into the feeding tbe, reinsert the stylet, and reposition the tube.
B) RePOSIliOn the patient from side to side.
C) Irrigate the tube with tap water.
(DY Stop any enteral feedings and obtain an order for a chest X-ray to determine placement.
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?
Yfi 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 afier 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
