The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of
the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What
actions do you take on the basis of this information? (Select all that apply.)
1. Notify the health care provider immediately
2. Repeat the measurements on both arms using a stethoscope
3. Ask the patient if she has taken her blood pressure medications recently
4. Obtain blood pressure measurements on lower extremities
5. Verify that the correct cuff size was used during the measurements
6. Review the patient's record for her baseline vital signs
7. Compare right and left radial pulses for strength
Give this one a try later!
2, 6
CH. 30
,A faculty member is reviewing a nursing student's plan of care, including the
interventions the student provided for a patient with dementia. The student reviewed
clinical guidelines on a professional website to identify interventions successful in
reducing wandering in patients with dementia. The faculty member should evaluate
which of the following? (Select all that apply.)
1. Number of interventions
2. Appropriateness of the intervention for the patient
3. The prior use of interventions by other nursing staff
4. Correct application of the intervention for the patient care setting
5. The time it takes to provide interventions
Give this one a try later!
2, 4
CH. 20
A nurse has been gathering physical assessment data on a patient and is now listening
to the patient's concerns. The nurse sets a goal of care that incorporates the patient's
desire to make treatment decisions. This is an example of the nurse engaged in which
phase of the nurse-patient relationship?
1. Working phase
2. Preinteraction phase
3. Termination phase
4. Orientation phase
Give this one a try later!
, 1
CH. 24
When should a nurse wear a mask? (Select all that apply.)
1. The patient's dental hygiene is poor.
2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested
cough.
4. The patient is in droplet precautions.
5. The nurse is assisting a health care provider in the insertion of a central line
catheter.
Give this one a try later!
2, 4, 5
CH. 29
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke
and a recent fall. His wife stated that he has a history of high blood pressure, which is
controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided
neglect and problems with spatial and perceptual abilities and is impulsive. He has
moderate left-sided weakness that requires the assistance of two and the use of a gait
belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary
catheter in place. Which factors increase his fall risk at this time? (Select all that apply.)
1. Smokes a pack a day
2. Used a cane to walk at home
3. Takes antihypertensive and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities, impulsive
, 6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter
Give this one a try later!
3, 4, 5, 6, 7
CH. 27
Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
1. Fluid Volume Excess related to heart failure
2. Sleep Deprivation related to sustained noisy environment
3. Impaired Bed Mobility related to postcardiac catheterization
4. Ineffective Protection related to inadequate nutrition
5. Diarrhea related to frequent, small, watery stools.
Give this one a try later!
2, 4
CH. 17
As you are obtaining the oxygen saturation on a 19-year-old college student with
severe asthma, you note that she has black nail polish on her nails. You remove the
polish from one nail, and she asks you why her nail polish had to be removed. What is
the best response?
1. Nail polish attracts microorganisms and contaminates the finger sensor.
2. Nail polish increases oxygen saturation.
3. Nail polish interferes with sensor function.
4. Nail polish creates excessive heat in sensor probe.
the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What
actions do you take on the basis of this information? (Select all that apply.)
1. Notify the health care provider immediately
2. Repeat the measurements on both arms using a stethoscope
3. Ask the patient if she has taken her blood pressure medications recently
4. Obtain blood pressure measurements on lower extremities
5. Verify that the correct cuff size was used during the measurements
6. Review the patient's record for her baseline vital signs
7. Compare right and left radial pulses for strength
Give this one a try later!
2, 6
CH. 30
,A faculty member is reviewing a nursing student's plan of care, including the
interventions the student provided for a patient with dementia. The student reviewed
clinical guidelines on a professional website to identify interventions successful in
reducing wandering in patients with dementia. The faculty member should evaluate
which of the following? (Select all that apply.)
1. Number of interventions
2. Appropriateness of the intervention for the patient
3. The prior use of interventions by other nursing staff
4. Correct application of the intervention for the patient care setting
5. The time it takes to provide interventions
Give this one a try later!
2, 4
CH. 20
A nurse has been gathering physical assessment data on a patient and is now listening
to the patient's concerns. The nurse sets a goal of care that incorporates the patient's
desire to make treatment decisions. This is an example of the nurse engaged in which
phase of the nurse-patient relationship?
1. Working phase
2. Preinteraction phase
3. Termination phase
4. Orientation phase
Give this one a try later!
, 1
CH. 24
When should a nurse wear a mask? (Select all that apply.)
1. The patient's dental hygiene is poor.
2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning.
3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested
cough.
4. The patient is in droplet precautions.
5. The nurse is assisting a health care provider in the insertion of a central line
catheter.
Give this one a try later!
2, 4, 5
CH. 29
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke
and a recent fall. His wife stated that he has a history of high blood pressure, which is
controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided
neglect and problems with spatial and perceptual abilities and is impulsive. He has
moderate left-sided weakness that requires the assistance of two and the use of a gait
belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary
catheter in place. Which factors increase his fall risk at this time? (Select all that apply.)
1. Smokes a pack a day
2. Used a cane to walk at home
3. Takes antihypertensive and diuretics
4. History of recent fall
5. Neglect, spatial and perceptual abilities, impulsive
, 6. Requires assistance with activity, unsteady gait
7. IV line, urinary catheter
Give this one a try later!
3, 4, 5, 6, 7
CH. 27
Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
1. Fluid Volume Excess related to heart failure
2. Sleep Deprivation related to sustained noisy environment
3. Impaired Bed Mobility related to postcardiac catheterization
4. Ineffective Protection related to inadequate nutrition
5. Diarrhea related to frequent, small, watery stools.
Give this one a try later!
2, 4
CH. 17
As you are obtaining the oxygen saturation on a 19-year-old college student with
severe asthma, you note that she has black nail polish on her nails. You remove the
polish from one nail, and she asks you why her nail polish had to be removed. What is
the best response?
1. Nail polish attracts microorganisms and contaminates the finger sensor.
2. Nail polish increases oxygen saturation.
3. Nail polish interferes with sensor function.
4. Nail polish creates excessive heat in sensor probe.
