Fundamentals of Nursing NCLEX Style: 200 Questions and Answers with Rationale, Exams of Nursing

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When evaluating a patient, what other signs and symptoms may a nurse observe if a hypertension patient is present besides high blood pressure values?

A) Unexplained pain and hyperactivity

B) Headache, Flushing of the face, and Nosebleed

C) Dizziness, Mental Confusion, and Mottled Extremities

D) Restlessness and dusky or cyanotic skin that is cool to the touch - CORRECT ANSWERS B- Headache, Flushing of the face, and Nosebleed

Which of the following values for vital signs would a nurse address first?

A) Heart Rate = 72 bpm

B) Respiratory Rate = 28 bpm

C) Oxygen Saturation by pulse oximetry = 89%

D) Blood Pressure = 160/

E) Temperature = 37.2° C (99° F), tympanic - CORRECT ANSWERS C- Oxygen Saturation by pulse oximetry = 89%

(Remember ABCs)

An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of

breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care?

A) Respiration rate = 20 breaths per minute

B) Oxygen saturation by pulse oximetry = 92%

C) Blood pressure = 138/

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D) Temperature = 39° C (102° F), tympanic - CORRECT ANSWERS D- Temperature = 39° C (102° F), tympanic

The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." (means the client may be up as desired.)What action should the nurse take?

A) Give him some slippers and tell him where the bathroom is located.

B) Ask the nursing assistant to assist him to the bathroom.

C) Obtain orthostatic blood pressure measurements.

D) Tell him it is not a good idea and provide a urinal. - CORRECT ANSWERS C- Obtain orthostatic blood pressure measurements.

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next?

A) Check the client's temperature history.

B) Document the results; temperature is normal.

C) Recheck the temperature every 15 minutes until it is normal.

D) Get another thermometer; the temperature is obviously an error. - CORRECT ANSWERS A- Check the client's temperature history.

(looking for a fluctuation in temperature)

The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision?

A) The client is in shock.

B) The client has an arrhythmia.

C) The client underwent surgery 18 hours earlier.

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C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic.

D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered. - CORRECT ANSWERS D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable?

A) Vasodilation and redistribution of blood to surface vessels

B) Sweating, vasodilation, and redistribution of blood to surface vessels

C) Vasoconstriction, sweating, and reduction of blood flow to extremities

D) Vasoconstriction, reduction of blood flow to extremities, and shivering - CORRECT ANSWERS D) Vasoconstriction, reduction of blood flow to extremities, and shivering

The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by:

A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference

B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference

C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference

D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference - CORRECT ANSWERS C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern?

A) Respirations cease for several seconds.

B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea.

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C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise.

D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea. - CORRECT ANSWERS D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions?

A) Check other vital signs.

B) Recheck the blood pressure and give the client orange juice.

C) Recheck the blood pressure after ambulating the client safely.

D) Recheck the blood pressure, make sure the client is safe, and report the findings. - CORRECT ANSWERS D) Recheck the blood pressure, make sure the client is safe, and report the findings.

52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant:

a) temperature

b) radial pulse

c) respiratory rate

d) oxygen saturation - CORRECT ANSWERS c) respiratory rate

Place the vital signs in order of priority for your nursing interventions:

1. SpO2= 89%

2. BP= 160/86 mmHG

3. Temperature= 37.3 (99.4)

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d. hypoxia

e. stress

Which of the following are signs of hyperthermia (fever)?

a. bradypnea

b. malaise

c. pale skin

d. shivering

e. decreased muscle coordination

f. tachycardia - CORRECT ANSWERS b. malaise

d. shivering

f. tachycardia

When are rectal temperatures contraindicated? - CORRECT ANSWERS newborns and patients with neuropenia, spinal cord injuries, diarrhea, rectal disease/surgery, and quadriplegia

How frequently is vital sign assessment done for stable patients? - CORRECT ANSWERS 4 to 8 hours

Which factors can lead to hypoventilation - CORRECT ANSWERS drug overdose, obesity, COPD, cervical spine injury

What steps are included in assessment of pain? - CORRECT ANSWERS SOCRATES

site, onset, character, radiation, associated signs and symptoms, time pattern, exacerbating/relieving factors, and severity

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What are nonverbal indications that a patient is experiencing pain? - CORRECT ANSWERS grimacing, pulling away from touch, changes in vital signs, agitation, and restlessness

Where is the correct location for the temporal artery temperature measurement? - CORRECT ANSWERS center of the forehead and then moved across to the hairline by the temple. If there is perspiration present, the probe should be touched to the skin behind the earlobe over the mastoid process

Irregular and apical pulses should be counted for - CORRECT ANSWERS 60 seconds

What is the pulse used for blood pressure measurement in the lower extremity? - CORRECT ANSWERS popliteal pulse

To prevent hypothermia in an older adult patient, the nurse instructs the patient to do what? - CORRECT ANSWERS dress in layers

use a blanket

wear scarf and gloves and hat

keep extremities covered

keep thermostat at 68F

Which side of the dual head is used for higher-pitched sounds? - CORRECT ANSWERS diaphragm

which of the following factors will result in a decrease in a patient's blood pressure?

a. pain

b. head injury

c. hemorrhage

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The nurse instructs the aide that a falsely low blood pressure reading will be obtained by which of the following methods?

a. using a cuff that is too narrow

b. releasing the pressure valve too slowly

c. assessing the blood pressure after the patient exercises

d. placing the arm above the level of the heart - CORRECT ANSWERS d. placing the arm above the level of the heart

A patient comes to the emergency department after having been in the sun all day. The nurse also determines that the patient is taking a diuretic. Heat stroke is suspected, and the nurse observes for which of the following?

a. diaphoresis

b. confusion

c. temperature of 35 to 37 C

d. decreased heart rate - CORRECT ANSWERS b. confusion

The nurse is taking vital signs on a 6 yr old child who has just finished a grape popsicle. Which of the following is an appropriate action?

a. wait 30 minutes to take the oral temperature

b. proceed to take a tympanic temperature reading

c. take a rectal temperature measurement

d. have the child rinse out the mouth and take the oral temperature - CORRECT ANSWERS B- proceed to take a tympanic temperature reading

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The adult patient is seen in the 24 hr medicenter for heat exhaustion. The nurse anticipates that treatment will include which of the following?

a. fluid replacement

b. antibiotic therapy

c. hypothermia wraps

d. tepid water baths - CORRECT ANSWERS a. fluid replacement

On entering the room, the nurse observes that the patient appears to be tachypneic. The nurse should:

a. ask if there have been visitors

b. have the patient lie flat

c. take the radial pulse

d. measure the respiratory rate - CORRECT ANSWERS d. measure the respiratory rate

The patient is experiencing pain and asks for medication, which has been ordered by the provider. The nurse first assess the vital signs and finds them to be: blood pressure 144/82, pulse 88/min, and respiration 24/min. The nurse should:

a. give the medication as ordered

b. check again that the patient has pain

c. withhold the medication

d. wait 20 minutes and check the vital signs again before giving the medication - CORRECT ANSWERS a. give the medication as ordered

For a patient who needs the blood pressure measured in the lower extremities, the nurse knows that the measurement will be:

a. the same as the upper extremity

b. 20 mm Hg lower than in the brachial artery

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The patient gets out of bed to go to the bathroom and tells the nurse that he "feels dizzy." The nurse should first:

a. go for help

b. take the blood pressure

c. help the patient to sit down

d. have the patient take deep breaths - CORRECT ANSWERS c. help the patient sit down

A teenage patient with the flu is febrile and needs the body temperature reduced. The nurse anticipates that treatment will include which of the following?

a. ice packs to the axilla and groin

b. a cooling blanket

c. an ice water bath

d. aspirin - CORRECT ANSWERS b. a cooling blanket

When measuring vital signs, the nurse is aware that blood pressure is usually lower in the presence of or following:

a. anxiety

b. exercise

c. cigarette smoking

d. diuretic administration - CORRECT ANSWERS d. diuretic administration

A patient asks the nurse about whether her blood pressure is too high. The nurse informs the patient that the blood pressure associated with stage 1 hypertension is:

a. 120/

b. 130/

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c. 140/

d. 160/110 - CORRECT ANSWERS c. 140/

A primary concern for a patient with orthostatic hypotension is the:

a. risk of injury

b. fluid overload

c. oxygen demand

d. mental confusion - CORRECT ANSWERS a. risk of injury

A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.)

a. Agitation

b. Restlessness

c. Sighing

d. Vital signs

e. Shivering - CORRECT ANSWERS ANS: A, B, D

The American Society for Pain Management in Nursing's position paper states that for the unconscious, intubated, dementia, or pre-verbal pediatric patient objective assessments of agitation, restlessness, irritation, and changes in vital signs can be used to help assess pain.

A nurse notes a patient has abnormal vital signs. What action by the nurse is best?

a. Document the findings.

b. Notify the provider.

c. Compare with prior readings.

d. Retake the vital signs. - CORRECT ANSWERS ANS: C

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The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.)

a. Brain

b. Lungs

c. Heart

d. Liver

e. Skeletal muscle - CORRECT ANSWERS ANS: A, B, C

Problems in the brain, heart, and lungs can directly lead to changes in respiratory rate and effort. Problems in the liver and skeletal muscle do not affect respirations directly.

The nurse understands that which factors can increase blood pressure? (Select all that apply.)

a. Head injury

b. Decreased fluid volume

c. Increasing age

d. Recent food intake

e. Pain - CORRECT ANSWERS ANS: A, C, D, E

Head injury, increasing age, recent food intake, pain, and increased (not decreased) fluid volume all can increase blood pressure.

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)

a. "Let me know if Mr. Smith's blood pressure is low."

b. "Take Mrs. Jones' blood pressure every 15 minutes."

c. "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg."

d. "Do you want me to demonstrate using the electronic blood pressure cuff?"

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e. "I'll take Mr. Derby's blood pressure since he is not stable." - CORRECT ANSWERS ANS: B, C, D, E

The nurse can delegate measuring vital signs to UAPs if the patient is stable. The nurse must ensure the UAP knows the proper technique for taking vital signs and knows which readings must be reported. Telling the UAP to report a blood pressure that is "too low" is too vague.

The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)

a. Monitor body systems functioning.

b. Identify early signs of problems.

c. Evaluate effectiveness of interventions.

d. Determine if a cure has been obtained.

e. Provide a baseline to compare against. - CORRECT ANSWERS ANS: A, B, C, E

Vital signs give information on the functioning of body systems, can lead the nurse to identify early signs of problems, can be used to evaluate the effectiveness of interventions, and provide a baseline to compare against subsequent readings. They are not used to solely determine if a disease has been cured.

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best?

a. "The patient's metabolic rate is increased from being ill."

b. "The lungs are trying to rid the body of extra carbon dioxide."

c. "The patient is trying to reduce his temperature through panting."

d. "Patients who are acutely ill often have abnormal vital signs." - CORRECT ANSWERS ANS: B

The body tries to compensate for excess carbon dioxide (seen in acidosis) by increasing the rate and depth of respirations to "blow off" the carbon dioxide.

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d. Reassess the blood pressures in 1 hour. - CORRECT ANSWERS ANS: A

This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?

a. 28

b. 42

c. 58

d. 66 - CORRECT ANSWERS ANS: D

The pulse pressure is the difference between the systolic and diastolic blood pressure readings. In this case, 142 - 76 = 66.

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?

a. Move the oximeter probe to another finger.

b. Assess the fingers for good circulation.

c. Document that the reading cannot be obtained.

d. Remove any fingernail polish present on the fingernail. - CORRECT ANSWERS ANS: B

A patient who is hypothermic may not have good circulation to the extremities. The nurse should assess the patient's circulation, and if it is poor to the extremities, choose another spot at which to measure the oxygen saturation. Moving the probe to another finger or removing nail polish will not help if the problem is poor circulation. The nurse should document appropriately, but needs to do more than just charting that the reading could not be obtained.

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A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?

a. Encourage deep breathing and coughing.

b. Medicate the patient for pain as needed.

c. Keep the head of the bed elevated.

d. Monitor the length of time the patient doesn't breathe. - CORRECT ANSWERS ANS: C

Orthopnea is difficulty breathing in positions other than sitting up. To assist the patient who has orthopnea, the nurse keeps the head of the bed elevated to ease breathing.

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member?

a. Counts pulse for 30 seconds and multiplies by two.

b. Performs hand hygiene prior to patient contact.

c. Compares pulses in both carotid arteries at the same time.

d. Assesses pulse on one side then assesses the other side. - CORRECT ANSWERS ANS: C

The carotid arteries are the main supply route of blood to the brain. Compressing both sides of the carotid arteries at the same time can lead to ischemia. The other actions are appropriate.

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is best?

a. Assess the patient for fluid volume overload.

b. Assess the patient for fluid volume deficit.

c. Assess the patient's apical heart rate.

d. Assess the patient's pulse deficit. - CORRECT ANSWERS ANS: A

A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume overload, or overhydration. The nurse should assess for this situation. The other actions are not necessary.