NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
      A)
      Wrap the blood pressure cuff snugly around the arm.
      B)
      Center the cuff bladder over the brachial artery.
      C)
      Place the client's arm above the level of the heart.
      D)
      Check the instrument gauge to ensure the reading starts at zero
    2. If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)
      A)
      pulse deficit
      B)
      diastolic
      C)
      auscultatory gap
      D)
      widened pulse pressure
    3. A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:
      A)
      check the patient's record to determine his baseline blood pressure.
      B)
      notify the charge nurse of the hypotension.
      C)
      check medications that might be the cause of the irregularity.
      D)
      notify the doctor of the bradycardia.
    4. The nurse taking a blood pressure should:
      A)
      place the arm so that the brachial artery is at waist level.
      B)
      chat with the patient to reduce any anxiety in the patient.
      C)
      request that the patient put feet flat on the floor.
      D)
      position the patient so that the arm is level with the shoulder.
    Page 1 of 12

    Exam Review

    1. A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
      A)
      After palpating the abdomen
      B)
      Prior to percussing the abdomen
      C)
      After checking for kidney tenderness
      D)
      Prior to inspecting the abdomen
    2. When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:
      A)
      increase in temperature.
      B)
      decrease in pulse.
      C)
      decrease in blood pressure.
      D)
      decrease in respirations.
    3. Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:
      A)
      pump up the cuff until no sound is heard and then let the air out.
      B)
      stop midway and begin to inflate again.
      C)
      make sure the bell of the stethoscope is placed firmly over the artery.
      D)
      continue to listen until the cuff is deflated.
    4. The nurse would record a pulse as bradycardic if the rate were:
      A)
      62 beats/min.
      B)
      59 beats/min.
      C)
      64 beats/min.
      D)
      60 beats/min.
    Page 2 of 12

    Exam Review

    1. If dehydration occurs, the blood pressure will
      A)
      become muffled.
      B)
      decrease.
      C)
      remain the same.
      D)
      Increase
    2. The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:
      A)
      54 mm Hg
      B)
      80 mm Hg.
      C)
      64 mm Hg.
      D)
      14 mm Hg.
    3. When checking extraocular movements, the nurse asks the patient to follow an object as it is moved into different positions and watch to see if
      A)
      the eyes move in a normal coordinated manner.
      B)
      the pupils dilate when focusing on the object.
      C)
      there is blinking while trying to focus on the object.
      D)
      the pupils constrict focusing on the object.
    4. If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?
      A)
      Wait 30 minutes and take the pressures again.
      B)
      Record both pressures in the medical record.
      C)
      Retake the pressure on both arms.
      D)
      Retake the pressure on the left arm.
    Page 3 of 12

    Exam Review

    1. The nurse covers a newborn baby's head with a cap. because the head:
      A)
      allows loss of body heat.
      B)
      an be reshaped more quickly.
      C)
      is wet and needs to be dried.
      D)
      has large fontanels.
    2. A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is
      A)
      Kussmaul's respirations.
      B)
      Cheyne-Stokes respirations.
      C)
      Biot's respirations.
      D)
      Hyperventilation.
    3. To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:
      A)
      push the soles of the feet against the nurse's hands.
      B)
      wiggle the toes of both feet at the same time.
      C)
      pull both feet up at the same time to stretch the Achilles tendons.
      D)
      stand up independently
    4. A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?
      A)
      "When I shine a light into the patient's eyes, the pupils should constrict."
      B)
      "It is normal for the pupils to react sluggishly to light."
      C)
      "When I shine a light into the patient's eyes, the pupils should dilate
      D)
      "Pupil checks should be performed with the room lights on."
    Page 4 of 12

    Exam Review

    1. It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:
      A)
      the beginning of each shift.
      B)
      admission to the unit.
      C)
      discharge.
      D)
      the patient's wakening in the morning.
    2. The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:
      A)
      measuring the oxygenated hemoglobin through a capillary bed.
      B)
      assessing the amount of blood passing through the sensor.
      C)
      assessing the relative warmth of the skin on the monitored part.
      D)
      measuring the respirations to the blood pressure via infrared rays.
    3. During a health interview, an older adult patient has difficulty remembering information about the health history. In order to get the information more reliably, the nurse should:
      A)
      gather information from a family member accompanying the patient.
      B)
      omit the interview and proceed to a physical examination.
      C)
      repeat the questions at the end of the visit to cross check for accuracy of data.
      D)
      reassure the patient that forgetfulness is a normal part of the aging process.
    4. Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:
      A)
      allow the patient to sit on the side of the bed for a minute before standing.
      B)
      instruct the patient to use the wheelchair for all mobility activity.
      C)
      keep the patient in bed in a high Fowler's position
      D)
      help the patient to rise quickly and support the patient for a minute.
    Page 5 of 12

    Exam Review

    1. When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)
      A)
      Persistent cough
      B)
      Difficulty in swallowing
      C)
      Changes in pulse rate
      D)
      Obvious change in a mole
      E)
      Vesicular breath sounds
      F)
      Hyperactive bowel sounds
    2. A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?
      A)
      temperature
      B)
      pulse
      C)
      blood pressure
      D)
      respirations
    3. The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction when the caregiver states, "I will
      A)
      instruct the patient to remain on strict bed rest
      B)
      provide the patient with additional blankets"
      C)
      encourage the patent to increase his muscle activity”
      D)
      offer fluids to the patient if permitted
    4. The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of
      A)
      lordosis
      B)
      osteoporosis
      C)
      kyphosis
      D)
      Scoliosis
    Page 6 of 12