Exam Review
- The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?A)Explain the procedure to the child.B)Choose the cuff that says "Child" instead of "Infant."C)Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.D)Obtain the reading before the child has a chance to settle down
- A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?A)Calcium channel blockerB)Angiotensin II receptor blocker (ARBS)C)Angiotensin-converting enzymes (ACE) inhibitorsD)Beta-blockers
- A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?A)Aortic and MitralB)Mitral and PulmonicC)Mitral and TricuspidD)Aortic and Pulmonic
- A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?A)Aortic and MitralB)Mitral and PulmonicC)Mitral and TricuspidD)Aortic and Pulmonic
Exam Review
- Which action should the nurse take when using critical thinking to make clinical decisions?A)Reads and follows the health care provider's orders.B)Accepts one established way to provide care.C)Makes decisions based on intuition.D)Consider what is important in any given situation.
- A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?A)Assess the pedal pulses for a full minuteB)Assess the apical pulse with a doppler deviceC)Assess the apical pulse for a full minute.D)Assess the pedal pulses with a Doppler device
- The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient?A)You will need to use a stethoscope properly.B)You can move your arm during the readingC)You can apply the cuff in any mannerD)You will need to recalibrate the machine
- A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication?A)HypertensionB)ConstipationC)BradycardiaD)Sedation
Exam Review
- A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?A)Hold the hands higher than the elbows.B)Rub hands and arms to dry.C)Apply 4 to 5 mL of liquid soap to the hands.D)Adjust the water temperature to feel hot.
- A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?A)Muscular strength assessmentB)Sensation assessmentC)Sleep assessmentD)Pulse oximetry assessment
- A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?A)Shortness of breathB)Adequate dietary intakeC)Decrease level of consciousnessD)Muscular Pain
- The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority?A)Pressure pointsB)Pulse pointsC)Breath soundsD)Bowel sounds
Exam Review
- The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage.A)Call the health care provider, a blockage is present in the tubing.B)Remove the drain, a drain is no longer needed.C)Do nothing as long as the evacuator is compressedD)Chart the results on the intake and output flow sheet
- A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?A)Making a clinical decision in the patient's best interest.B)Making a clinical decision based on previous shift assessments.C)Making an ethical clinical decisionD)Making an informed clinical decision
- The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shearing. Which score will the nurse document for this patient?A)23B)15C)17D)20
- The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?A)Primary IntentionB)Partial-thickness repairC)Secondary IntentionD)Tertiary intention
Exam Review
- A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?A)AV NodeB)SA NodeC)Purkinje FibersD)Bundle of HIS
- A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?A)Myocardial contractility x myocardial blood flowB)Ventricular filling time/diastolic filling timeC)Stroke volume times the heart rateD)Preload/afterload
- The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of the RN?A)Assessing changes in body temperature.B)Being aware of the usual values for the patient.C)Obtaining temperature measurements at ordered frequency.D)Using appropriate route and device
- While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?A)Left-sided heart failureB)Myocardial ischemiaC)Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veinsD)Atrial fibrillation
Exam Review
- Convert from Fahrenheit to Celsius: 98.6
- A nurse caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide to the client's parents on administering the medication?A)Give the medication in the morning daily.B)Administer the medication 2 hours before exerciseC)Administer the granules mixed with 20 ounces of waterD)Give the medication at the onset of wheezing
- A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?A)Tell the client to blow his/her nose gently before the instillation of the drops.B)Assist the client to a side-lying position.C)Hold the dropper 2 cm (1 inch) above the naresD)Instruct the client to stay in the same position for 2 minutes.
- The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?A)Stage I Pressure UlcerB)Stage III Pressure UlcerC)Healing Stage III Pressure UlcerD)Healing Stage II Pressure Ulcer