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Exam Study Questions
Terms in this set (28)
A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?
30 to 60 breaths per minute
A nurse applies a cuff of the automated blood pressure device around the client's arm in preparation for serial blood pressure recordings. The nurse checks the cuffed arm frequently based on which rationale?
ensure adequate arterial perfusion
A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person?
A mother of a newborn asks the nurse why the body temp of her baby is unstable. What response would be most appropriate?
It is because of the immature ability to regulate temperature in general.
A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?
what devices are used to measure blood pressure?
sphygmomanometer, automated oscillometric device, and doppler device
A nurse is assessing a client's respirations and notes that they are cyclical in nature, with shallow breaths alternating with periods of apnea. What breathing pattern is this?
What would cause falsely high blood pressure readings?
Client is anxious when reading was taken, the cuff was deflated too slowly, the cuff was wrapped unevenly, the cuff was too small for the client.
The nurse hears faint, clear tapping sounds when obtaining a client's blood pressure. What phase of korotkoff sounds is this?
Phase 1 - systolic pressure
(II: swishing sound
III: intense sounds
IV: muffled blowing sounds)
Assessment of a client's bowel sounds is best obtained by performing which assessment technique?
Which of the following is an example of subjective data?
What would a nurse ensure before beginning a health assessment?
That the room is private, quiet, warm, and has adequate light
A nurse is caring for a patient who is experiencing acute pain in the lower back. Which condition would the nurse interpret as an objective finding?
A. reduced pulse
B dilated pupils
C. high fever
D. low blood pressure
A nurse is preparing to assess a client with abdominal pain. What should the nurse do when preparing the client for assessment?
Explain the assessment procedure to the client
A nurse is percussing a client's abdomen. What would the nurse identify as a normal finding?
Tympany, the sound is characterized in terms of intensity and loudness
The nurse performs the Weber test on and older client with a conductive hearing loss. What is expected to be found?
Client hears vibrations in the affected ear. A client with conductive hearing loss best hears vibrations of the activated tuning fork in the affected ear.
While auscultating the chest, the nurse hears swishing sounds through the stethoscope, resembling systolic murmurs. What would the nurse suspect?
A. reduced blood flow across a normal valve
B. blood flow through a normal opening between heart chambers
C. forward blood flow caused by a leaky valve
D. partially obstructed blood flow through valve opening
Partially obstructed blood flow through a valve opening.
(Increased blood flow across a normal valve, backward blood flow caused by a leaky valve, blood flow into a dilated chamber, and blood flow through abnormal openings between the heart chambers are the causes of murmur)
A nurse is auscultating a client's chest and notices adventitious breath sounds. The nurse suspects atelectasis and asks the client to repeat the word "ninety-nine." The nurse hears the sound louder and more clearly than normal. The nurse documents this as:
IN preparing a care plan for a client receiving opioid analgesics, the nurse selcts which of the following as an applicable nursing diagnosis associated with side effects of opiod use?
B. Bowel incontinence
C. Impaired urinary elimination
Who can best determine the experience of pain?
the person who has the pain
A nurse asks a client to rate his pain on a scale of 0 to 10. What characteristic of pain is the nurse assessing?
A nurses assesses a client who is being given an opioid analgesic and finds the client unresponsive to shaking or other stimuli. What drug might be ordered to reverse this state?
Naloxone (is an opioid antagonist that reverses the respiratory depressant effects of opioids)
A middle-age client is reporting acute joint pain to a nurse who is assessing the client's pain in a clinic. Which question related to pain assessment should the nurse ask the client?
Does your pain level change after taking medication?
During and older client does not mention pain in his initial assessment. Which belief is common in older adult clients that may cause them to underreport their pain?
pain is a normal part of aging
Which of the following can be identified as the first component in the transmission of the pain stimulus?
B. A-delta fibers
C. Spinothalamic tract
D. C fibers
A client complains of a dull, aching pain to his right flank where he was struck during a football game one week ago. What is responsible for the transmission of such pain?
A client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment?
A client comes to the emergency department reporting a shooting pain in his chest. When assessing the client's behavioral responses, what would the nurse expect to find?
Frowning and grimacing
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