Nursing Test Bank NURS204 Final Exams 2024, Exams of Nursing

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Nursing Test Bank NURS204 Final

Exams 2024

Which types of nurses make the best communicators with patients? a. Those who learn effective psychomotor skills b. Those who develop critical thinking skills c. Those who like different kinds of people d. Those who maintain perceptual biases - ✔B A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend - ✔C A nurse wants to present information about flu immunizations to the older adults in the community. Which type of communication should the nurse use? a. Public b. Small group c. Interpersonal d. Intrapersonal - ✔A A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? a. Interpersonal communication to change negative self-talk to positive self-talk b. Small group communication to present information to an audience c. Electronic communication to assess a patient in another city d.

Intrapersonal communication to build strong teams - ✔C A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. Which element will the nurse identify as feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good. - ✔D A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Socio-consultative b. Personal c. Intimate d. Public - ✔B A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's denotative meaning is wrong. b. The patient's personal space was violated. c. The patient's affect is inappropriate. d. The patient's vocabulary is poor. - ✔C The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d.

Vocabulary - ✔B A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Nonjudgmental b. Socializing c. Narrative d. SBAR - ✔C Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination - ✔A During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination - ✔B A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working

d. Termination - ✔C A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? a. To promote autonomy b. To use common courtesy c. To establish trustworthiness d. To standardize communication - ✔D A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed - ✔C A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are." - ✔B An older-adult patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Chew gum. b. Turn off the television. c. Speak clearly and loudly. d.

Use at least 14-point print. - ✔B A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure - ✔A When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "You will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?" - ✔D Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond. - ✔A A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues. - ✔B

The staff is having a hard time getting an older-adult patient to communicate. Which technique should the nurse suggest the staff use? a. Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. Involve only the patient in conversations. - ✔B A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostomy - ✔D A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. - ✔A Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately b. Uses automatic responses fluently c. Demonstrates passive remarks accurately d. Self-examines personal communication skills - ✔D A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive?

a. "I think you've had a hard day." b. "I feel uncomfortable hearing that statement." c. "I don't think you should say things like that. It is not right." d. "I have been checking on you regularly. How can you say that?" - ✔B Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith b. Uses humility c. Portrays self-confidence d. Exhibits supportiveness e. Demonstrates independent attitude - ✔B, C, E A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed b. An older-adult patient who is demanding c. A female patient who is outgoing and flirty d. A male patient who is cooperative with treatments e. An older-adult patient who can clearly see small print f. A teenager frightened by the prospect of impending surgery - ✔A, B, C, F A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reads the patient's plan of care. b. The student nurse reviews the patient's medical record. c. The student nurse shares patient information with a friend.

d. The student nurse documents medication administered to the patient. - ✔C A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? a. A verbal report b. An electronic record entry c. A referral d. An acuity rating - ✔A A nurse is auditing and monitoring patients' health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients' health records b. Realizing that care not documented in patients' health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients' records d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment - ✔A After providing care, a nurse charts in the patient's record. Which entry will the nurse document? a. Appears restless when sitting in the chair b. Drank adequate amounts of water c. Apparently is asleep with eyes closed d. Skin pale and cool - ✔D A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. Status unchanged, doing well b. Patient seems to be in pain and states, "I feel uncomfortable."

c. Left knee incision 1 inch in length without redness, drainage, or edema d. Patient is hard to care for and refuses all treatments and medications. Family is present.

• ✔C A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up? a. The new nurse documents only for self. b. The new nurse charts consecutively on every other line. c. The new nurse ends each entry with signature and title. d. The new nurse keeps the password secure. - ✔B A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally? a. Charts legibly b. States the patient is belligerent c. Writes entry for another nurse d. Uses correction fluid to correct error - ✔A A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find? a. Electronic medical record b. Electronic health record c. Electronic charting record d. Electronic problem record - ✔B A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? a. Patient went up and down stairs b.

Demonstrated use of crutches c. Used crutches with no difficulties d. Deficient knowledge related to never using crutches - ✔B A nurse wants to find the daily weights of a patient. Which form will the nurse use? a. Database b. Progress notes c. Patient care summary d. Graphic record and flow sheet - ✔D A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Add this data to the problem list. b. Focus chart using the DAR format. c. Document the variance in the patient's record. d. Report a positive variance in the next interdisciplinary team meeting. - ✔C A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order - ✔A A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c.

Standardized care plan d. Signature for verbal order - ✔B A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third-party payers - ✔D A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a. A minimum data set b. An admission assessment and acuity level c. A focused assessment/specific body system d. An intake assessment form and auditing phase - ✔A A nurse is charting. Which information is critical for the nurse to document? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient received a pain medication, Lortab. d. The family is poor and had to go on welfare. - ✔C A nurse is completing an OASIS data set on a patient. The nurse works in which area? a. Home health b. Intensive care unit c. Skilled nursing facility d. Long-term care facility -

✔A

A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include? a. The family is a "pain." b. Pupils equal and reactive to light c. Had poor results from the pain medication d. Sharp pain of 8 on a scale of 1 to 10 - ✔D A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? a. As the nurse and health care provider leave a patient's room, the primary care provider gives the nurse an order. b. At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. c. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. d. A nurse reads an order correctly as written by the health care provider in the patient's medical record. - ✔B A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN. - ✔C A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a.

Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system - ✔C A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided. - ✔D A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. - ✔A A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. b. A clinical information system must be installed by 2014 to obtain health care reimbursement. c. A "near miss" helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care. - ✔A

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts - ✔B A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure - ✔C A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation - ✔C The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation - ✔B

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees. - ✔C The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation. - ✔D The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient's temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety. - ✔A A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cuff d. Sphygmomanometer - ✔B

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms - ✔C The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c. Restrict the patient's fluid intake. d. Increase the patient's metabolic rate - ✔A The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency - ✔B The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature? a. Oral b. Rectal c. Axillary d. Tympanic - ✔D

The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Temporal - ✔C The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse? a. Radial b. Brachial c. Femoral d. Popliteal - ✔B The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial - ✔C The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist. c. Place the thumb over the groove along the little finger side of the patient's wrist. d.

Place the thumb over the groove along the thumb side of the patient's wrist. - ✔A The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations. - ✔C The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium - ✔C The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. Give CO2 via mask. - ✔B A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg -

✔D

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions. - ✔D The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on. - ✔B The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? a. Red blood cell count of 5.0 million/mm b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95% - ✔B A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult

d. 146/90 in an older adult - ✔C The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African-Americans d. Asian Americans - ✔C A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement. - ✔C When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler. - ✔A The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism. -

✔B

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair. - ✔B The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site - ✔C The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15 - ✔A The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler's earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler's nose. d. Overlook variations between an oximeter pulse rate and the toddler's pulse rate. - ✔B

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b. Obtain the reading before the child has a chance to "settle down." c. Choose the cuff that says "Child" instead of "Infant." d. Explain the procedure to the child. - ✔D A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 - ✔C 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 can apply the cuff in any manner. b. You will need to recalibrate the machine. c. You can move your arm during the reading. d. You will need to use a stethoscope properly. - ✔B The nurse is caring for a patient who reports feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. b. Perform an apical/radial pulse assessment. c. Call the health care provider immediately. d. Obtain arterial blood gases. -

✔B

A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d. An 87-year-old male suspected of hypothermia whose temperature is below normal - ✔B The health care provider prescription reads "Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure b. Does not inform the health care provider that the medication was held c. Does not tell the patient what the blood pressure is d. Documents only what the blood pressure was. - ✔A After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures. - ✔A When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62

d. 138/70 - ✔C The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP retake the blood pressure. b. Instruct the NAP to assess the patient's other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient's condition. - ✔D A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery - ✔B, C, E The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice - ✔B, C, D, E, F

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action? a. Prevention of atelectasis b. Prevention of renal calculi c. Prevention of pressure ulcers d. Prevention of joint contractures - ✔D A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation - ✔B A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a. Thermometer b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices - ✔C The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a. Maintain a narrow base of support. b. Dangle the patient at the bedside. c. Encourage isometric exercises. d. Suggest a high-calcium diet. - ✔B A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?