front 1 A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include? | back 1 Encourage the client to practice relaxation techniques each day. |
front 2 A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? | back 2 A client who has stabilized BP measurements |
front 3 A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? | back 3 The AP informs the client when they are counting the respirations. |
front 4 A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include? | back 4 a client who has a blood pressure of 162/102 mm Hg has stage II hypertension. |
front 5 A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? | back 5 SaO2 97% right index finger, room air |
front 6 A nurse is assessing a 3-month-old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? | back 6 Place the stethoscope over the 4th intercostal space to the left of the sternum. |
front 7 A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their respiratory rate that requires intervention? | back 7 A school-age child who has a respiratory rate of 14/min |
front 8 A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature? | back 8 A client who is diaphoretic and frequently chewing ice to relieve dry mouth |
front 9 A nurse is reviewing the vital signs for a group of clients obtained by an assistive personnel. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? | back 9 A young adult who has a radial pulse rate of 56/min |
front 10 A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? | back 10 Body temperature is typically lower in older adults. |
front 11 A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? | back 11 An 11-year-old child who has a respiratory rate of 34/min |
front 12 A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia | back 12 A young adult who has an apical pulse rate of 104/min |
front 13 A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? | back 13 Recording vital signs provides critical information regarding a client's condition. |
front 14 A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? | back 14 Apex of the heart |
front 15 A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? | back 15 Instruct the client to bear down like they are having a bowel movement. |
front 16 A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? | back 16 "Radiation is the loss of body heat when a client is in close proximity to a cooler surface." |
front 17 A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include? | back 17 Fever can increase a client's respiratory rate. |
front 18 A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect | back 18 Increase in blood pressure |
front 19 A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? (Select all that apply.) | back 19 Provide the client with low-sodium meals and snacks. |
front 20 A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene? | back 20 Toddler who has a respiratory rate of 44/min |
front 21 A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? | back 21 Oxygen saturation reflects the amount of oxygen being delivered to body tissues. |
front 22 A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include? | back 22 "Count the respiratory rate for 1 minute for clients who have a respiratory infection." |
front 23 A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) | back 23 Select the site for obtaining the measurement is the first
step. |
front 24 A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range? | back 24 A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg |
front 25 A nurse is preparing an in-service about vital signs for a group of newly hired assistive personnel. Which of the following information should the nurse include about measuring body temperature? | back 25 Oral temperature is easily accessible despite a client's position. |
front 26 A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take? | back 26 Encourage the client to change positions slowly. |
front 27 A charge nurse is evaluating a newly licensed nurse's documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete? | back 27 BP 124/82 mm Hg, lying in bed |
front 28 A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about body temperature. Which of the following information should the nurse include? | back 28 A temporal probe thermometer uses infrared scanning to determine a client's temperature. |
front 29 A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include? | back 29 Blood pressure is measured and documented in millimeters of mercury |
front 30 A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse? | back 30 Dyspnea |
front 31 A nurse is discussing the use of a client's thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include? | back 31 Use the thigh to obtain blood pressure when a client has severe edema in their arms. |
front 32 A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? | back 32 A client has a radial pulse of +4 bilateral. |
front 33 A nurse is observing an assistive personnel (AP) who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse? | back 33 The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second. |
front 34 A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? | back 34 8-year-old male: respiratory rate 34/min, SaO2 97% |
front 35 A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? (Select all that apply.) | back 35 A preschooler who was exhibiting tachypnea 2 hr postoperative and now
has a respiratory rate of 26/min |
front 36 A charge nurse is reviewing the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? | back 36 "Hypertension is diagnosed with two elevated measurements on two separate occasions." |
front 37 A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? | back 37 An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min. |
front 38 A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vital signs should the nurse identify is outside the expected reference range and notify the provide | back 38 A client who has an apical pulse rate of 120/min |
front 39 A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching? | back 39 "The body lowers body temperature through sweating." |
front 40 A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? | back 40 Sinoatrial (SA) node |
front 41 A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next? | back 41 Obtain a manual blood pressure reading from the client. |
front 42 A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? | back 42 Pulmonary artery |
front 43 A nurse is reviewing the recent vital signs of a group of clients. Which of the following clients should the nurse see first? | back 43 A 52-year-old client who has an SaO2 of 92% |
front 44 A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? | back 44 A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation. |
front 45 A nurse is planning care for a group of clients and is delegating to the assistive personnel (AP) to take the clients' vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP? | back 45 A client who was recently admitted and reports chest pain |
front 46 A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the client's heart rate? | back 46 Encourage the client to reduce intake of caffeinated soft drinks. |
front 47 A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? | back 47 Inform the client to ask for assistance with getting out of bed. |
front 48 A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? | back 48 Decrease in contractility |
front 49 A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response? | back 49 smoking |
front 50 A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? | back 50 Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall. |
front 51 A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? | back 51 A bronchodilator |
front 52 A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? | back 52 A 3-year-old preschooler who has an apical pulse rate of 144/min |
front 53 A nurse is evaluating the effectiveness of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse? | back 53 Left radial pulse is nonpalpable |
front 54 A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtained simultaneous pulse rates. The client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following? | back 54 Pulse deficit of 13/min |
front 55 A nurse is caring for a client who has an increase in cardiac output. Which of the following findings should the nurse expect? | back 55 Increase in blood pressure |
front 56 A nurse is evaluating the effectiveness of interventions used to address clients' vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? | back 56
A young adult who is experiencing an asthma attack and has a
blood pressure of 116/72 mm |
front 57 A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? | back 57 "Cardiac output is the amount of blood flow through the heart in 1 minute." |