Ramont2e Rev TIF Ch21
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Transcript of Ramont2e Rev TIF Ch21
8/20/2019 Ramont2e Rev TIF Ch21
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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test
Bank
Chapter 21Question 1
Type: MCSA
The nurse would measure vital signs more frequently than every 4 hours for which of the following clients?
1. The client with a diagnosis of terminal cancer admitted for palliative care
2. The client who is 6 days postoperative and is to be discharged tomorrow
3. The client admitted as an outpatient for ! hours while receiving a blood transfusion
. The client who is "6 hours postoperative and stable
Corre!t "ns#er: "
Rationa$e 1# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %
minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&
The other clients would require vital signs every 4 hours unless a complication or change in condition arose&
Rationa$e 2# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %
minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&
The other clients would require vital signs every 4 hours unless a complication or change in condition arose&
Rationa$e 3# A client receiving blood transfusions requires vital signs before beginning the transfusion$ %minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&
The other clients would require vital signs every 4 hours unless a complication or change in condition arose&
Rationa$e # A client receiving blood transfusions requires vital signs before beginning the transfusion$ %
minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed&The other clients would require vital signs every 4 hours unless a complication or change in condition arose&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrityC$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# 'lanning
(earning ut!ome: (dentify times when vital signs should be measured&
Question 2
Type: MCSA
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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3. The client is hypertensive$ and the physician should be notified&
. The pulse is borderline low$ and requires further assessment&
Corre!t "ns#er: 4
Rationa$e 1# The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the
child$ or the child could have a problem& *emaining vital signs are within normal limits&
Rationa$e 2# The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the
child$ or the child could have a problem& *emaining vital signs are within normal limits&
Rationa$e 3# The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the
child$ or the child could have a problem& *emaining vital signs are within normal limits&
Rationa$e # The client2s pulse is borderline low$ and further assessment is needed$ as this could be normal for the
child$ or the child could have a problem& *emaining vital signs are within normal limits&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: (dentify normal ranges for each vital sign by age&
Question
Type: MCSA
The nursing student is ta.ing blood pressures at a health3screening fair in the local mall& A !63year3old woman
who is seven months pregnant has a blood pressure reading of 46:99& 0hich of the following actions does the
nursing student ta.e?
1. Tell the client that she has a normal blood pressure&
2. Call 9 for an ambulance because the blood pressure is dangerously high&
3. Advise the client to notify her physician immediately of the results&
. Advise the woman to go home$ rest$ and put her feet up&
Corre!t "ns#er: "
Rationa$e 1# The blood pressure for this client is too high$ and the client is advised to contact her physicianimmediately& There is no evidence that the client is in any distress$ so calling 9 is unnecessary& The blood
pressure$ however$ is too high to send the client home to rest& The pregnant client might run a slightly higher
pressure than normal for her age$ but$ this blood pressure is an indication of problems for the client and her baby&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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Rationa$e 3# The client is e<hibiting all the signs of hypothermia& 1ital signs are all decreased$ so the client is note<periencing pyre<ia >fever$ or a remittent fever$ which would occur with an elevated temperature& There is no
such thing as vital sign crisis&
Rationa$e # The client is e<hibiting all the signs of hypothermia& 1ital signs are all decreased$ so the client is not
e<periencing pyre<ia >fever$ or a remittent fever$ which would occur with an elevated temperature& There is nosuch thing as vital sign crisis&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analy@ing
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect temperature and its accurate measurement&
Question
Type: MCSA
0hen measuring temperature on a client who comes to the clinic drin.ing coffee$ the nurse would use what route
1. ral
2. *ectal
3. Tympanic
. A<illary
Corre!t "ns#er: "
Rationa$e 1# The best route for measuring temperature would be tympanic& ral is contraindicated because the
client is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing
for the client$ and is not required in order to get an accurate temperature&
Rationa$e 2# The best route for measuring temperature would be tympanic& ral is contraindicated because theclient is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing
for the client$ and is not required in order to get an accurate temperature&
Rationa$e 3# The best route for measuring temperature would be tympanic& ral is contraindicated because theclient is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassingfor the client$ and is not required in order to get an accurate temperature&
Rationa$e # The best route for measuring temperature would be tympanic& ral is contraindicated because the
client is drin.ing hot coffee& A<illary would be less accurate than would tympanic& *ectal would be embarrassing
for the client$ and is not required in order to get an accurate temperature&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
Copyright !/! by 'earson +ducation$ (nc&
8/20/2019 Ramont2e Rev TIF Ch21
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%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analy@ing
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect temperature and its accurate measurement&
Question /
Type: MCSA
The nurse measures pulse rate on a young adult male and obtains a rate of 44 per minute& The nurse would
consider this pulse rate normal if which of the following data were assessed?
1. The client is on Bano<in >digo<in for heart disease&
2. The client is an athlete&
3. The client has awasa.i2s disease&
. The client has a congenital cardiac defect&
Corre!t "ns#er: !
Rationa$e 1# 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms of
reduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes
strengthen their cardiac muscle$ resulting in increased stro.e volume$ requiring a lower pulse rate to meet tissuedemands& A heart rate of 44 would be considered abnormal and potentially dangerous for all of the other options&
Rationa$e 2# 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms of
reduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes
strengthen their cardiac muscle$ resulting in increased stro.e volume$ requiring a lower pulse rate to meet tissuedemands& A heart rate of 44 would be considered abnormal and potentially dangerous for all of the other options&
Rationa$e 3# 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms of
reduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes
strengthen their cardiac muscle$ resulting in increased stro.e volume$ requiring a lower pulse rate to meet tissuedemands& A heart rate of 44 would be considered abnormal and potentially dangerous for all of the other options&
Rationa$e # 0hen all other vital signs and assessments are normal$ and the client has no signs or symptoms ofreduced perfusion$ the nurse would consider the pulse rate acceptable if the client were an athlete& Athletes
strengthen their cardiac muscle$ resulting in increased stro.e volume$ requiring a lower pulse rate to meet tissuedemands& A heart rate of 44 would be considered abnormal and potentially dangerous for all of the other options&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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The nurse is wor.ing in the )(C, and is caring for an infant who weighs %// grams& The child is being
monitored$ and has several electrodes on the chest& The nurse is unable to hear the apical pulse through the
electrodes$ and does not want to remove the electrodes and damage the infant2s s.in& The nurse chec.s the infant2s
pulse at which of the following sites?
1. -rachial artery
2. *adial artery
3. 'edal artery
. Dugular artery
Corre!t "ns#er:
Rationa$e 1# The brachial artery would be the best choice for this infant if the apical pulse were not an option&
The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not an
artery&
Rationa$e 2# The brachial artery would be the best choice for this infant if the apical pulse were not an option&The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not an
artery&
Rationa$e 3# The brachial artery would be the best choice for this infant if the apical pulse were not an option&
The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not anartery&
Rationa$e # The brachial artery would be the best choice for this infant if the apical pulse were not an option&
The radial and pedal arteries might not have enough pressure to adequately assess& The Eugular is a vein$ not anartery&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: 'oint to the nine sites commonly used to assess the pulse and state the reasons each sitemight be used&
Question 1
Type: MCSA
The nurse is caring for a 5/3year3old client who suddenly becomes confused and tells the nurse she has to go
catch the bus& The nurse assesses which of the following before notifying the physician?
1. 'resence of an apical pulse rate
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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2. The strength of the radial artery
3. 'resence of carotid pulses bilaterally
. The femoral pulses
Corre!t "ns#er: "
Rationa$e 1# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid
perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$
before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial arterystrength and femoral pulses would not apply to the situation&
Rationa$e 2# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid
perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$
before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial arterystrength and femoral pulses would not apply to the situation&
Rationa$e 3# The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$
before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial arterystrength and femoral pulses would not apply to the situation&
Rationa$e # The client might be e<periencing decreased blood flow to the brain as a result of reduced carotid
perfusion& The nurse would lightly palpate for the carotid arteries$ ta.ing care to palpate only one side at a time$ before notifying the physician& 'resence of an apical pulse is indicated by the client2s spea.ing$ and radial artery
strength and femoral pulses would not apply to the situation&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analy@ing
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: 'oint to the nine sites commonly used to assess the pulse and state the reasons each site
might be used&
Question 11
Type: MCMA
The nurse assesses the client2s pulse for which of the following? Select all that apply&
)tandard Tet: Select all that apply&
1. *ate
2. *hythm
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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3. Strength
. -ilateral equality
-. Stro.e volume
Corre!t "ns#er: $!$"$4
Rationa$e 1# Stro.e volume cannot be determined by assessing the pulse& All other options should be included
when assessing pulse&
Rationa$e 2# Stro.e volume cannot be determined by assessing the pulse& All other options should be includedwhen assessing pulse&
Rationa$e 3# Stro.e volume cannot be determined by assessing the pulse& All other options should be included
when assessing pulse&
Rationa$e # Stro.e volume cannot be determined by assessing the pulse& All other options should be included
when assessing pulse&
Rationa$e -# Stro.e volume cannot be determined by assessing the pulse& All other options should be included
when assessing pulse&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: (dentify normal ranges for pulse rate and quality when assessing a client2s pulse&
Question 12
Type: MCMA
0hen assessing the apical3radial pulse using the two3nurse method$ the nurses include which of the following?
Select all that apply&
)tandard Tet: Select all that apply&
1. 'lace the client supine with the =- elevated "/ degrees&
2. Bocate the 'M( and radial pulses&
3. Bocate the femoral pulses&
. +ach nurse counts for "/ full seconds&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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. ;iminished breath sounds
Corre!t "ns#er: !
Rationa$e 1# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the
same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw
respirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&
Rationa$e 2# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain thesame o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw
respirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&
Rationa$e 3# At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the
same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3sawrespirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&
Rationa$e # At a higher altitude$ there is less o<ygen in the atmosphere$ requiring faster respirations to obtain the
same o<ygen acquired at lower elevations& The respirations would increase to try to obtain more o<ygen& See3saw
respirations are uneven breathing$ and diminished breath sounds are not a part of counting respirations&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect respiration and its accurate measurement&
Question 1
Type: MCSA
The nurse assesses respirations on a postoperative client receiving morphine every four hours$ and anticipates
which of the following?
1. Morphine could cause a decrease in respirations&
2. The client could be in pain and have increased respirations&
3. The client might have increased respirations due to an<iety&
. The client will have normal respirations&
Corre!t "ns#er:
Rationa$e 1# Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased
respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ and
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
Copyright !/! by 'earson +ducation$ (nc&
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morphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but theanticipation would be for a slower rate&
Rationa$e 2# Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased
respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ and
morphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but theanticipation would be for a slower rate&
Rationa$e 3# Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased
respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ andmorphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but the
anticipation would be for a slower rate&
Rationa$e # Morphine is a narcotic$ and affects the respiratory center of the brain$ resulting in decreased
respirations& The effects of the morphine are li.ely to overcome any increase in respirations caused by pain$ andmorphine usually reduces client an<iety& (t would not be abnormal to find a normal respiratory rate$ but the
anticipation would be for a slower rate&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect respiration and its accurate measurement&
Question 1-
Type: MCSA
The nurse assesses the infant2s respirations as normal when which of the following is noted?
1. (ntercostal retractions
2. Substernal retractions
3. ,se of accessory muscles when breathing
. Abdominal breathing
Corre!t "ns#er: 4
Rationa$e 1# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as
the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratory
distress$ and occur because the infant uses accessory muscles to draw in more air&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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Rationa$e 2# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations asthe result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratory
distress$ and occur because the infant uses accessory muscles to draw in more air&
Rationa$e 3# (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as
the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratorydistress$ and occur because the infant uses accessory muscles to draw in more air&
Rationa$e # (nfants have immature chest muscles$ and rely more on abdominal breathing during respirations as
the result of the wor. of the diaphragm& *etractions of any .ind are always abnormal$ indicating respiratorydistress$ and occur because the infant uses accessory muscles to draw in more air&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe the mechanics of breathing and identify the components of a respiratory
assessment&
Question 1
Type: MCSA
The nurse is preparing to assess blood pressure on the client& 0hen the nurse enters the room$ the client is being
assisted bac. to bed by the physical therapist following therapy& The nurse does which of the following?
1. Measures blood pressure quic.ly so the client can rest&
2. 0aits for the therapist to get the client in bed and measure vital signs&
3. *equests permission from the client to measure vital signs&
. *eturns to measure vital signs in /3% minutes&
Corre!t "ns#er: 4
Rationa$e 1# The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to res
and return in /3% minutes to measure blood pressure&
Rationa$e 2# The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to res
and return in /3% minutes to measure blood pressure&
Rationa$e 3# The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to res
and return in /3% minutes to measure blood pressure&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
Copyright !/! by 'earson +ducation$ (nc&
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Rationa$e # The client2s blood pressure will be elevated after e<ercise$ so the nurse should allow the client to resand return in /3% minutes to measure blood pressure&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect blood pressure and its accurate measurement&
Question 1/
Type: MCSA
The nursing student is practicing blood pressure s.ills at a screening clinic& After ta.ing a client2s blood pressure
several times$ the student tells the instructor that the orot.off2s sounds cannot be heard& 'rior to the instructor2s
measuring blood pressure$ the nurse should do which of the following to improve accuracy?
1. =ave the instructor apologi@e to the client for repeated cuff inflation&
2. =ave the client pump his fist to improve volume of orot.off2s sounds&
3. Move the cuff to the other arm&
. =ave the client elevate his arm&
Corre!t "ns#er: "
Rationa$e 1# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The studentshould have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i
could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the
brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&
Rationa$e 2# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The student
should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i
could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the
brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&
Rationa$e 3# *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgement
of the artery& The cuff should be moved to the other arm before performing another measurement& The student
should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although icould have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the
brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
Copyright !/! by 'earson +ducation$ (nc&
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Rationa$e # *epeated inflation of the cuff causes false elevation of blood pressure due to repeated engorgementof the artery& The cuff should be moved to the other arm before performing another measurement& The student
should have been the one to apologi@e to the client$ and fist pumping will not alter orot.off2s sounds$ although i
could have an adverse effect on accuracy of the measurement& -lood pressures should be measured with the brachial pulse at heart level$ and elevation of the arm will create a falsely low reading&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;escribe factors that affect blood pressure and its accurate measurement&
Question 10
Type: MCSA
0hen measuring blood pressure$ the nurse identifies the systolic blood pressure at the pressure when which of thefollowing occurs?
1. orot.off2s sounds develop a muffled whooshing quality&
2. The first of at least two tapping sounds are heard in phase &
3. The first sound is heard during phase &
. A muffled blowing quality
Corre!t "ns#er: !
Rationa$e 1# The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneous
sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in phase !$ while a muffled blowing quality develops in phase 4&
Rationa$e 2# The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneous
sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in
phase !$ while a muffled blowing quality develops in phase 4&
Rationa$e 3# The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneous
sounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in phase !$ while a muffled blowing quality develops in phase 4&
Rationa$e # The nurse listens for at least two consecutive tapping sounds to ensure that they are not e<traneoussounds$ and then labels the first sound as the systolic blood pressure& A muffled whooshing sound is heard in
phase !$ while a muffled blowing quality develops in phase 4&
%$o&a$ Rationa$e:
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Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: ;ifferentiate systolic from diastolic blood pressure and describe five phases of orot.off2ssounds&
Question 1
Type: MCMA
The nurse measures a clientFs vital signs according to agency policy$ as well as#>Select all that apply
)tandard Tet: Select all that apply&
1. -efore discharge
2. At least every si< hours if the client has had an elevated temperature within the past !4 hours
3. -efore calling the physician
. -efore transfer to a new unit
-. n admission to a facility
Corre!t "ns#er: $"$4$%
Rationa$e 1# The nurse measures the clientFs vital signs prior to discharge to ensure the clientFs condition has not
changed
Rationa$e 2# The clientFs vitals signs should be measured at least every 4 hours if the client has had an eleveated
temperature within the past !4 hours
Rationa$e 3# The nurse measures the clientFs vital signs before calling the physician as part of the data collection
Rationa$e # The nurse measures the clientFs vital signs prior to transferring the client to another unit to determin
any change in condition$ as well as having the data to report to the receiving unit
Rationa$e -# The nurse measures the clientFs vital signs on admission to a facility to determine a baseline
measurement
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
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(earning ut!ome:
Question 2
Type: MCMA
The nursing assistant reports vital signs from a 4"3year3old client to the nurse$ who reports the abnormal
measurements to the physician& The following measurements are normal for the 4"3year3old client#>Select all that
apply
)tandard Tet: Select all that apply&
1. Temperature of 96&7G oral
2. 'ulse rate of /4
3. Temperature of "57C oral
. -lood pressure of /:%/
-. *espirations of 5:minute
Corre!t "ns#er: "$4$%
Rationa$e 1# The normal temperature for a 4"3year3old is 9&6
Rationa$e 2# The normal temperature for a 4"3year3old is 9&6
Rationa$e 3# The normal temperature for a 4"3year3old is 9&6
Rationa$e # The normal temperature for a 4"3year3old is 9&6
Rationa$e -# The normal temperature for a 4"3year3old is 9&6
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 21
Type: G(-
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The neonatal nurse is measuring the vital signs of a !3day3old infant& The mother e<presses concern about the
babyFs blood pressure& The nurse e<plains that the neonates diastolic blood pressure is normally HHHHHHH mm=g
less than the normal adults&
)tandard Tet:
Corre!t "ns#er:
Rationa$e # The normal neonatal blood pressure is 5":%%8 the normal adult blood pressure is !/:/
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 22
Type: MCMA
A client returns to the nursing unit after laporoscopic surgery& The nurse prepares to ta.e the clientFs vital signs at
several intervals$ including#>Select all that apply
)tandard Tet: Select all that apply&
1. +very % minutes for first hour
2. +very "/ minutes for second and third hours
3. +very hour for fourth through seventh hours
. +very "/ minutes for three hours
-. +very four hours from return from surgery
Corre!t "ns#er: $!$"
Rationa$e 1# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable
Rationa$e 2# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable
Rationa$e 3# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable
Rationa$e # The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable
Rationa$e -# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable
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%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 23
Type: MCSA
The nurse modifies her schedule to be certain to ta.e a clientFs vital signs before and after routine administration
of which of the following types of medications?
1. Antipyretics
2. Antibiotics
3. Anticoagulants
. Antihelmintics
Corre!t "ns#er:
Rationa$e 1# The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature
Rationa$e 2# The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature
Rationa$e 3# The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature
Rationa$e # The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrityC$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 2
Type: S+I
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There are several sites for assessing a clientFs temperature& The nurse understands that each method has benefits$
and that accuracy of each method is different& *an. the methods of temperature measurement from most to least
accurate
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. *ectal
Choi!e 2. Tympanic
Choi!e 3. ral
Choi!e . A<illary
Corre!t "ns#er: $!$"$4
Rationa$e 1# The most accurate means of measuring temperature is rectally because this is a measurement of the
core temperature
Rationa$e 2# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature
Rationa$e 3# The most accurate means of measuring temperature is rectally because this is a measurement of the
core temperature
Rationa$e # The most accurate means of measuring temperature is rectally because this is a measurement of the
core temperature
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts:
(earning ut!ome:
Question 2-
Type: MCMA
The nurse is caring for a client with hyperthyroidism$ who has been e<periencing fevers& The nurse understandsthat a number of factors affect the bodyFs heat production$ including#>Select all that apply
)tandard Tet: Select all that apply&
1. -asal metabolic rate
2. Thyro<ine output
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3. Sympathetic stimulation
. Jender
-. Jenetics
Corre!t "ns#er: $!$"$4
Rationa$e 1# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing
Rationa$e 2# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essentialactivities such as breathing
Rationa$e 3# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing
Rationa$e # The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing
Rationa$e -# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts:
(earning ut!ome:
Question 2
Type: MCMA
0hen ma.ing initial rounds$ the nurse notes a clientFs shivering& 0hish of the following processes are stimulated
by the hypothalamus to increase the body temperature#>Select all that apply
)tandard Tet: Select all that apply&
1. Shivering
2. Sweating
3. 1asoconstriction
. 1asodilation
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-. (ncreased respiratory rate
Corre!t "ns#er: $"
Rationa$e 1# The hypothalamus stimulates shivering to increase heat production
Rationa$e 2# The hypothalamus stimulates shivering to increase heat production
Rationa$e 3# The hypothalamus stimulates shivering to increase heat production
Rationa$e # The hypothalamus stimulates shivering to increase heat production
Rationa$e -# The hypothalamus stimulates shivering to increase heat production
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts:
(earning ut!ome:
Question 2/
Type: MCSA
0hen planning to assess a clientFs temperature$ the nurse reali@es that the safest$ least invasive method of
temperature measurement is#
1. *ectal
2. ral
3. A<illary
. Tympanic membrane
Corre!t "ns#er: "
Rationa$e 1# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can cause
inEury to rectum
Rationa$e 2# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can cause
inEury to rectum
Rationa$e 3# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to rectum
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Rationa$e # 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to rectum
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: Safe +ffective Care +nvironment
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 20
Type: MCMA
'rior to delegating temperature measurement to assistive personnel$ the nurse determines the appropriate method
of measuring the clientFs temperature& Safety considerations include#>Select all that apply
)tandard Tet: Select all that apply&
1. Gorcing the thermometer into place to ma.e sure it is accurate
2. Ma.ing sure the client .nows not to roll over when a rectal thermometer is in place
3. ,sing the blue tipped thermometer for an oral temperature
. ,sing a site other than oral if the client is .nown to have frequent sei@ures
-. ,sing probe covers e<cept for a<illary temperatures
Corre!t "ns#er: "$4
Rationa$e 1# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ andconsider a different location
Rationa$e 2# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and
consider a different location
Rationa$e 3# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ andconsider a different location
Rationa$e # Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and
consider a different location
Rationa$e -# Thermometers should never be forced into place8 if it does not enter easily$ reassess the site$ and
consider a different location
%$o&a$ Rationa$e:
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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Cogniti'e (e'e$: Applying
C$ient Need: Safe +ffective Care +nvironment
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 2
Type: MCMA
0hen ta.ing a %!3year3oldFs pulse rate$ the nurse considers which of the following factors that might increase the
clientFs pulse?>Select all that apply
)tandard Tet: Select all that apply&
1. Age
2. Stress
3. Gever
. Morning vital signs
-. =emorrhage
Corre!t "ns#er: !$"$%
Rationa$e 1# As age increases$ the pulse rate gradually decreases
Rationa$e 2# (n response to stress$ sympathetic nervous stimulation increases the rate as well as the force of the
heartbeat
Rationa$e 3# The pulse rate increases in response to the lowered blood pressure that results from peripheral
vasodilation associated with elevated body temperature and because of the increased metabolic rate
Rationa$e # 'ulse rate is lower in the morning and rises later in the day
Rationa$e -# Boss of blood from the vascular system normally increases pulse rate
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
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Question 3
Type: MCMA
The nurse measures a !/3year3oldFs pulse at %6 beats:minute at 5pm& 0hich of the following factors may be
responsible for a lower pulse rate?>Select all that apply
)tandard Tet: Select all that apply&
1. Age
2. +<ercise
3. Time of day
. +pinephrine
-. Standing up
Corre!t "ns#er: $!
Rationa$e 1# 'ulse rates increase as age increases8 the !/3year3old would usually have a pulse on the lower end o
normal
Rationa$e 2# Athletes normally have slower resting heart rates because of greater cardiac si@e$ strength and
efficiency
Rationa$e 3# 'ulse rate is higher later in the day and lower in the morning
Rationa$e # +pinephrine containing medications would normally cause an increase in the heart rate
Rationa$e -# 'ostural changes after sitting cause a transient decrease in venous blood return to the heart and a
subsequent reduction in blood pressure
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 31
Type: MCMA
0hen ta.ing the pulse of a child under three years of age$ the nurse will use which of the following sites#>Select
all that apply
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)tandard Tet: Select all that apply&
1. *adial
2. Apical
3. Carotid
. -rachial
-. 'edal
Corre!t "ns#er: !$"$4
Rationa$e 1# *adial is not routinely used for infants
Rationa$e 2# Apical pulse is routinely used for infants and children up to " years of age
Rationa$e 3# Carotid pulse is used for infants if brachial pulse is not accessible
Rationa$e # -rachial pulse is used during cardiac arrest for infants
Rationa$e -# 'edal pulses are assessed to determine circulation to the foot
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 32
Type: G(-
The nurse .nows that the pulse is commonly ta.e in any of HHHH sites&
)tandard Tet:
Corre!t "ns#er: 9
Rationa$e # The pulse is commonly measured from one of the following 9 sites# temporal$ carotid$ apical$
brachial$ radial$ femoral$ popliteal$ posterior tibial$ pedal
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 33
Type: MCMA
The nurse is preparing to measure a clientFs pulse& 0hich of the following are appropriate to use?>Select all that
apply
)tandard Tet: Select all that apply&
1. Thumb and inde< finger
2. Stethoscope
3. Three middle fingers
. ;oppler ultrasound stethoscope
-. Two last fingers
Corre!t "ns#er: !$"$4
Rationa$e 1# The thumb is not
Rationa$e 2# The thumb is not
Rationa$e 3# The thumb is not
Rationa$e # The thumb is not
Rationa$e -# The thumb is not
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 3
Type: MCSA
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Corre!t "ns#er: $"$%
Rationa$e 1# Thoracic >costal breathing involves the use of e<ternal intercostal muscles
Rationa$e 2# Abdominal breathing involves the contraction and rela<ation of the diaphragm
Rationa$e 3# Thoracic>costal breathing involves the use of accessory muscles
Rationa$e # ;iaphragmatic breathing involves contraction and rela<ation of the diaphragm
Rationa$e -# Costal breathing can be observed by the movement of the chest upward and outward
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 3
Type: MCMA
The nurse is assessing a clientFs respiratory status& (ndicators of normal respiratory status include#>Select all that
apply
)tandard Tet: Select all that apply&
1. +upnea
2. ,se of e<ternal intercostal muscles
3. Suprasternal retraction
. rthopnea
-. Apnea
Corre!t "ns#er: $!
Rationa$e 1# +upnea describes normal adult respirations$ !3!4 rpm depending on baseline
Rationa$e 2# The use of e<ternal intercostal muscles is a characteristic of normal thoracic respirations
Rationa$e 3# Suprasternal retraction$ the indrawing above the clavicles and sternum is not characteristic of norma
respirations
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Rationa$e # rthopnea$ the ability to breathe only in upright sitting or standing positions is not characteristic ofnormal respirations
Rationa$e -# Apnea$ the cessation of breathing$ is not characteristic of normal respirations
%$o&a$ Rationa$e:
Cogniti'e (e'e$: ApplyingC$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 3/
Type: MCMA
The nurse measures a clientFs respiratory rate at "4 rpm& The nurse reviews the clients chart and discovers the
following factors that may be causing the increase in respirations#>Select all that apply
)tandard Tet: Select all that apply&
1. Client is febrile
2. The client was Eust told about a poor prognosis
3. The client has been diagnosed with increased intracranial pressure
. The client was Eust medicated for pain
-. The clientFs body temperature is 967G
Corre!t "ns#er: $!
Rationa$e 1# The client who is febrile will often have an increased respiratory rate
Rationa$e 2# The client who is undergoing stress may have an increased respiratory rate as the body readies for
Kfight or flightL
Rationa$e 3# The client with increased intracranial pressure will show a decrease in respiratory rate
Rationa$e # Certain medications$ such as narcotics and analgesics will decrease the respiratory rate
Rationa$e -# The client with a decreased body temperature will show a decreased respiratory rate
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
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C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 30
Type: MCMA
0hile assessing a clientFs respirations as abnormal$ the nurse notes the following#>Select all that apply
)tandard Tet: Select all that apply&
1. The rate of respirations
2. The depth of respirations
3. The clientFs normal breathing patterns
. The relationship of respirations to cardiovascular function
-. Bac. of sound when breathing
Corre!t "ns#er: $!$"$4
Rationa$e 1# The nurse notes the rate of respirations$ by number$ as well as terms such as tachypnic$ bradypnic
Rationa$e 2# The nurse notes the depth of the clientFs respirations by watching the movement of the chest
Rationa$e 3# A change in the clientFs normal breathing pattern should be noted
Rationa$e # A client with compromised cardiovascular status is li.ely to have alterations in his or her respiratory
pattern$ with increased or decreased breath sounds$ respiratory rate or depth
Rationa$e -# )ormal breathing is silent
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 3
Type: MCMA
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The nurse is e<plaining the basic physiology and significance of blood pressure to a client who has been
hospitali@ed for hypertension& (nformation that is important to discuss includes#>Select all that apply
)tandard Tet: Select all that apply&
1. 1enous blood pressure is a measure of the force e<erted by the blood as it flows through the arteries
2. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles
3. The diastolic blood pressure is the lower pressure that is present at all times within the arteries
. -lood pressure is static
-. -lood pressure is recorded as a fraction
Corre!t "ns#er: !$"$%
Rationa$e 1# Arterial blood pressure is a measure of the force e<erted by the blood as it flows through the arteries
Rationa$e 2# The systolic pressure is the result of contraction of the ventricles8 the pressure at the height of the
blood wave
Rationa$e 3# The diastolic pressure it the pressure when ventricles are at rest
Rationa$e # -lood pressure is not static and normally changes from minute to minute
Rationa$e -# -lood pressure is measured in millimeters of mercury$ recorded as a fraction with the systolic pressure written above the diastolic pressure
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question
Type: MCMA
As the nurse assesses a clientFs blood pressure$ he or she understands that blood pressure is a result of#>Select all
that apply
)tandard Tet: Select all that apply&
1. The volume of blood pumped into the arteries by the heart
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Rationa$e 1# Age is a non3modifiable factor8 blood pressure increases with age from the newborn$ to the pea. atthe onset of puberty8 in older people$ the elasticity of the arteries is decreased which yields elevated systolic and
diastolic pressures
Rationa$e 2# -lood pressure is generally higher in overweight and obese people8 weight can be lost through diet
and e<ercise modification
Rationa$e 3# -lood pressure is usually lowest early in the morning$ when the metabolic rate is lowest
Rationa$e # 'hysical activity increases the cardiac output and the blood pressure
Rationa$e -# Many medications may increase of decrease the blood pressure$ and should be review if abnormal
measurements are determined
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 2
Type: MCSA
The community health nurse is holding a blood pressure chec. at a community center& 0hich of the following
measurements indicates Stage hypertension?
1. %:56
2. "6:
3. %4:9/
. 6!:9/
Corre!t "ns#er: "
Rationa$e 1# This blood pressure is within normal limits$ and should be rechec.ed in year
Rationa$e 2# This blood pressure indicates prehypertension$ and should be rechec.ed within 63! months
Rationa$e 3# This blood pressure indicates Stage hypertension$ and should be rechec.ed within month
Rationa$e # This blood pressure indicates a split category$ between stage and !$ and should be evaluated or
referred to a source of care within wee.
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%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need:
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 3
Type: MCSA
The nurse is caring for a client who has been on bedrest for several wee.s& The nurse ta.es precaution when
assisting the client to the chair due to the ris. of
1. =ypotension
2. =ypertension
3. rthostatic hypertension
. rthostatic hypotension
Corre!t "ns#er: 4
Rationa$e 1# =ypotension is a condition base on blood pressure that is below normal combined with the presence
of symptoms8 the information given does not support this answer
Rationa$e 2# =ypotension is a condition base on blood pressure that is below normal combined with the presence
of symptoms8 the information given does not support this answer
Rationa$e 3# =ypotension is a condition base on blood pressure that is below normal combined with the presence
of symptoms8 the information given does not support this answer
Rationa$e # =ypotension is a condition base on blood pressure that is below normal combined with the presence
of symptoms8 the information given does not support this answer
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need:C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question
Type: S+I
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orot.offFs sounds can be differentiated into five phases& Correlate the phase from 3% with the appropriate
choice&
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. Systolic blood pressure
Choi!e 2. Sounds have muffled$ whooshing$ swishing quality
Choi!e 3. Sounds become crisper$ more intense
Choi!e . Sounds become muffled$ soft blowing quality
Choi!e -. ;iastolic blood pressure
Corre!t "ns#er: $!$"$4$%
Rationa$e 1# 'hase is the pressure level at which the first faint$ clear tapping or thumping sounds are heart8 thefirst tapping sound heard during deflation of the cuff is the systolic blood pressure
Rationa$e 2# 'hase ! is the period during deflation when the sounds have a muffled$ whooshing$ or swishing
quality
Rationa$e 3# 'hase " is the period during which the blood flows freely through an increasingly open artery andthe sounds become crisper and more intense and again assume a thumping quality$ but softer than in phase
Rationa$e # 'hase 4 is the time when the sounds become muffled and have a soft$ blowing quality
Rationa$e -# 'hase % is the level when the last sound is heard8 the pressure at which the last sound is heard is the
diastolic blood pressure in adults
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -Type: MCMA
The nurse identifies factors that can cause errors in blood pressure measurement that yield higher results$ such as
>Select all that apply
)tandard Tet: Select all that apply&
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1. ,se of an electronic blood pressure device
2. ,se of an aneroid sphygmomanometer
3. ,se of a ;oppler ultrasound stethoscope
. A blood pressure cuff that is too small for the diameter of the clientFs arm
-. A blood pressure cuff that is too long
Corre!t "ns#er: $4
Rationa$e 1# *esearch indicates that automated electronic devices produce higher values than manual readings
Rationa$e 2# The manual sphygmomanometer will yield the most accurate measurement
Rationa$e 3# The use of a ;S is indicated when orot.offFs sounds are difficult to hear
Rationa$e # (f the bladder of the blood pressure cuff is too narrow for the clientFs arm the blood pressure readingwill be erroneously elevated
Rationa$e -# (f the blood pressure cuff is too long for the client$ the blood pressure reading will be erroneously
low
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question
Type: MCMA
The nurse is choosing the appropriate blood pressure cuff for a client& The following consideration affect the
decision#>Select all that apply
)tandard Tet: Select all that apply&
1. A small cuff may be used for a normal adult
2. The bladder of the blood pressure cuff must be 4/ of the arm circumference
3. A large cuff may be used to measure the blood pressure on the leg of an infant
. The same cuff may be used to measure the blood pressure of an infant or toddler
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-. A small cuff may be used with a frail adult
Corre!t "ns#er: !$%
Rationa$e 1# A small cuff is used for an infant$ small child or frail adult
Rationa$e 2# A small cuff is used for an infant$ small child or frail adult
Rationa$e 3# A small cuff is used for an infant$ small child or frail adult
Rationa$e # A small cuff is used for an infant$ small child or frail adult
Rationa$e -# A small cuff is used for an infant$ small child or frail adult
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question /
Type: MCMA
0hen preparing to assess a clientFs blood pressure$ the nurse observes for indications to using the clientFs thigh
for and standard stethoscope$ such as#>Select all that apply
)tandard Tet: Select all that apply&
1. ,nilateral mastectomy
2. (ntravenous infusions in both arms
3. -urns on upper body$ including shoulders or hands
. -ilateral mastectomy
-. Arteriovenous fistula
Corre!t "ns#er: !$"$4
Rationa$e 1# The client with a unilateral mastectomy should have the blood pressure measured on the not3affecte
arm
Rationa$e 2# The client with (1s in both arms should have the blood pressure measured on the thigh
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Rationa$e 3# The client with burns or trauma affecting the upper body$ including shoulders or hands >bilaterallyshould have the blood pressure measured on the thigh
Rationa$e # The client with bilateral mastectomies should have the blood pressure measured on the thigh
Rationa$e -# The client with an arteriovenous fistula should have the blood pressure measured on the non3affecte
arm
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 0
Type: S+I
The nurse uses the two3step palpatory blood pressure measurement to ensure accurate results& The steps are as
follows# 'lace the steps in the appropriate order
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. The blood pressure cuff is inflated until the brachial or radial pulse is occluded
Choi!e 2. The nurse notes the reading$ deflates the cuff
Choi!e 3. The nurse waits "/36/ seconds
Choi!e . Cuff is inflated !/3"/ mm=g higher than number noted
Corre!t "ns#er: $!$"$4
Rationa$e 1# The blood pressure cuff is inflated while palpating the radial or brachial pulse$ until the artery is
occluded and the pulse cannot be palpated
Rationa$e 2# The nurse notes the reading and deflates the cuff
Rationa$e 3# The nurse waits "/36/ seconds prior to reinflating cuff to allow blood flow to normali@e
Rationa$e # The cuff is inflated !/3"/ mm=g higher than the number noted on palpation$ and the rest of the procedure is the same as the auscultatory method
%$o&a$ Rationa$e:
Cogniti'e (e'e$:
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C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question
Type: MCMA
The nurse measures a clientFs vital signs according to agency policy$ as well as#
)tandard Tet: Select all that apply&
1. -efore discharge&
2. At least every 6 hours if the client has had an elevated temperature within the past !4 hours&
3. -efore calling the physician&
. -efore transfer to a new unit&
-. n admission to a facility&
Corre!t "ns#er: $"$4$%
Rationa$e 1# The nurse measures the clientFs vital signs prior to discharge to ensure that the clientFs condition hasnot changed&
Rationa$e 2# The clientFs vital signs should be measured at least every 4 hours if the client has had an elevated
temperature within the past !4 hours&
Rationa$e 3# The nurse measures the clientFs vital signs before calling the physician as part of data collection&
Rationa$e # The nurse measures the clientFs vital signs prior to transferring the client to another unit to determinany change in condition$ as well as to have the data to report to the receiving unit&
Rationa$e -# The nurse measures the clientFs vital signs on admission to a facility to determine a baseline
measurement&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: ApplyingC$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -
Type: MCMA
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The nursing assistant reports vital signs from a 4"3year3old client to the nurse$ who reports the abnormalmeasurements to the physician& The following measurements are normal for the 4"3year3old client#
)tandard Tet: Select all that apply&
1. Temperature of 96&7G oral
2. 'ulse rate of /4
3. Temperature of "57C oral
. -lood pressure of /:%/
-. *espirations of 5:minute
Corre!t "ns#er: "$4$%
Rationa$e 1# The normal temperature for a 4"3year3old is 9&67G&
Rationa$e 2# The normal temperature for a 4"3year3old is 9&67G&
Rationa$e 3# The normal temperature for a 4"3year3old is 9&67G&
Rationa$e # The normal temperature for a 4"3year3old is 9&67G&
Rationa$e -# The normal temperature for a 4"3year3old is 9&67G&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -1
Type: G(-
The neonatal nurse is measuring the vital signs of a !3day3old infant& The mother e<presses concern about the
babyFs blood pressure& The nurse e<plains that the neonateFs diastolic blood pressure is normally HHHHHHH mm=g
lower than the normal adultFs&
)tandard Tet:
Corre!t "ns#er: 5":%%
Rationa$e # The normal neonatal blood pressure is 5":%%8 the normal adult blood pressure is !/:/&
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%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -2
Type: MCMA
A client returns to the nursing unit after laparoscopic surgery& The nurse prepares to ta.e the clientFs vital signs atseveral intervals$ including#
)tandard Tet: Select all that apply&
1. +very % minutes for first hour&
2. +very "/ minutes for second and third hours&
3. +very hour for fourth through seventh hours&
. +very "/ minutes for three hours&
-. +very four hours from return from surgery&
Corre!t "ns#er: $!$"
Rationa$e 1# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&
Rationa$e 2# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&
Rationa$e 3# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&
Rationa$e # The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&
Rationa$e -# The nurse ta.es vital signs every % minutes for hour after surgery$ if vital signs remain stable&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: ApplyingC$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -3
Type: MCSA
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The nurse modifies her schedule to be certain to ta.e a clientFs vital signs before and after routine administrationof which of the following types of medications?
1. Antipyretics
2. Antibiotics
3. Anticoagulants
. Antihelmintics
Corre!t "ns#er:
Rationa$e 1# The nurse measures vital signs before and after administration of a medication that can impact vitalsigns8 an antipyretic is meant to reduce temperature&
Rationa$e 2# The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature&
Rationa$e 3# The nurse measures vital signs before and after administration of a medication that can impact vitalsigns8 an antipyretic is meant to reduce temperature&
Rationa$e # The nurse measures vital signs before and after administration of a medication that can impact vital
signs8 an antipyretic is meant to reduce temperature&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -
Type: S+I
There are several sites for assessing a clientFs temperature& The nurse understands that each method has benefits$
and that the accuracy of each method is different& *an. the methods of temperature measurement from most to
least accurate#
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. *ectal
Choi!e 2. Tympanic
Choi!e 3. ral
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Choi!e . A<illary
Corre!t "ns#er: $!$"$4
Rationa$e 1# The most accurate means of measuring temperature is rectally because this is a measurement of the
core temperature&
Rationa$e 2# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature&
Rationa$e 3# The most accurate means of measuring temperature is rectally because this is a measurement of thecore temperature&
Rationa$e # The most accurate means of measuring temperature is rectally because this is a measurement of the
core temperature&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: ApplyingC$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question --
Type: MCMA
The nurse is caring for a client with hyperthyroidism who has been e<periencing fevers& The nurse understands
that a number of factors affect the bodyFs heat production$ including#
)tandard Tet: Select all that apply&
1. -asal metabolic rate&
2. Thyro<ine output&
3. Sympathetic stimulation&
. Jender&
-. Jenetics&
Corre!t "ns#er: $!$"$4
Rationa$e 1# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing&
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Rationa$e 2# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essentialactivities such as breathing&
Rationa$e 3# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing&
Rationa$e # The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing&
Rationa$e -# The basal metabolic rate is the rate of energy utili@ation in the body required to maintain essential
activities such as breathing&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -
Type: MCMA
0hen ma.ing initial rounds$ the nurse notes a clientFs shivering& 0hich of the following processes are stimulated
by the hypothalamus to increase the body temperature?
)tandard Tet: Select all that apply&
1. Shivering
2. Sweating
3. 1asoconstriction
. 1asodilation
-. (ncreased respiratory rate
Corre!t "ns#er: $"
Rationa$e 1# The hypothalamus stimulates shivering to increase heat production&
Rationa$e 2# The hypothalamus stimulates shivering to increase heat production&
Rationa$e 3# The hypothalamus stimulates shivering to increase heat production&
Rationa$e # The hypothalamus stimulates shivering to increase heat production&
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Rationa$e -# The hypothalamus stimulates shivering to increase heat production&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -/
Type: MCSA
0hen planning to assess a clientFs temperature$ the nurse reali@es that the safest$ least invasive method oftemperature measurement is#
1. *ectal&
2. ral&
3. A<illary&
. 1ia the tympanic membrane&
Corre!t "ns#er: "
Rationa$e 1# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can cause
inEury to the rectum&
Rationa$e 2# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to the rectum&
Rationa$e 3# 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can cause
inEury to the rectum&
Rationa$e # 0hile rectal temperature measurement is the most reliable$ it is the most invasive$ and can causeinEury to the rectum&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: ApplyingC$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -0
Type: MCMA
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'rior to delegating temperature measurement to assistive personnel$ the nurse determines the appropriate methodof measuring the clientFs temperature& Safety considerations include#
)tandard Tet: Select all that apply&
1. Gorcing the thermometer into place to ma.e sure it is accurate&
2. Ma.ing sure the client .nows not to roll over when a rectal thermometer is in place&
3. ,sing the blue3tipped thermometer for an oral temperature&
. ,sing a site other than oral if the client is .nown to have frequent sei@ures&
-. ,sing probe covers$ e<cept for a<illary temperatures&
Corre!t "ns#er: "$4
Rationa$e 1# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and
consider a different location&
Rationa$e 2# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and
consider a different location&
Rationa$e 3# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and
consider a different location&
Rationa$e # Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ and
consider a different location&
Rationa$e -# Thermometers should never be forced into place8 if one does not enter easily$ reassess the site$ andconsider a different location&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question -
Type: MCMA
0hen ta.ing a %!3year3oldFs pulse rate$ the nurse considers which of the following factors that might increase theclientFs pulse?
)tandard Tet: Select all that apply&
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1. Age
2. Stress
3. Gever
. Morning vital signs
-. =emorrhage
Corre!t "ns#er: !$"$%
Rationa$e 1# As age increases$ the pulse rate gradually decreases&
Rationa$e 2# (n response to stress$ sympathetic nervous stimulation increases the rate as well as the force of theheartbeat&
Rationa$e 3# The pulse rate increases in response to the lowered blood pressure that results from peripheral
vasodilation associated with elevated body temperature$ and because of the increased metabolic rate&
Rationa$e # 'ulse rate is lower in the morning and rises later in the day&
Rationa$e -# Boss of blood from the vascular system normally increases pulse rate&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question
Type: MCMA
The nurse measures a !/3year3oldFs pulse at %6 beats:minute at 5 p&m& 0hich of the following factors might be
responsible for a lower pulse rate?
)tandard Tet: Select all that apply&
1. Age
2. +<ercise
3. Time of day
. +pinephrine
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Rationa$e 3# Carotid pulse is used for infants if brachial pulse is not accessible&
Rationa$e # -rachial pulse is used during cardiac arrest for infants&
Rationa$e -# 'edal pulses are assessed to determine circulation to the foot&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 2
Type: G(-
The nurse .nows that the pulse is commonly ta.en in any of HHHH sites&
)tandard Tet:
Corre!t "ns#er: 9
Rationa$e # The pulse is commonly measured from one of the following 9 sites# temporal$ carotid$ apical$
brachial$ radial$ femoral$ popliteal$ posterior tibial$ or pedal&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: nowledge
C$ient Need: 'hysiological (ntegrityC$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question 3
Type: MCMA
The nurse is preparing to measure a clientFs pulse& 0hich of the following are appropriate to use?
)tandard Tet: Select all that apply&
1. Thumb and inde< finger
2. Stethoscope
3. Three middle fingers
. ;oppler ultrasound stethoscope
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-. Two last fingers
Corre!t "ns#er: !$"$4
Rationa$e 1#
Rationa$e 2#
Rationa$e 3#
Rationa$e #
Rationa$e -#
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question
Type: MCSA
The nurse is caring for a client with C';& As they tal.$ the client as.s what the difference is between ventilation
and respiration& The nurse responds#
1. K*espiration is the inta.e of air into the lungs&L
2. K*espiration refers to the e<change of carbon dio<ide and o<ygen at the cellular level&L
3. K1entilation refers to the movement of air in and out of the lungs&L
. K1entilation refers to very shallow respirations&L
Corre!t "ns#er: "
Rationa$e 1# *espiration is the act of breathing&
Rationa$e 2# (nternal respiration refers to the e<change of carbon dio<ide and o<ygen at the cellular level betweenthe circulating blood and the cells of the body tissues&
Rationa$e 3# 1entilation refers to the movement of air in and out of the lungs&
Rationa$e # =ypoventilation refers to very shallow inadequate respirations&
%$o&a$ Rationa$e:
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Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question -
Type: MCMA
The nurse is assessing a clientFs respirations& Characteristics of costal breathing include#
)tandard Tet: Select all that apply&
1. ,se of e<ternal intercostal muscles&
2. Contraction of the diaphragm&
3. ,se of accessory muscles&
. Movement of the abdomen&
-. Movement of the chest upward and outward&
Corre!t "ns#er: $"$%
Rationa$e 1# Thoracic >costal breathing involves the use of e<ternal intercostal muscles&
Rationa$e 2# Abdominal breathing involves the contraction and rela<ation of the diaphragm&
Rationa$e 3# Thoracic >costal breathing involves the use of accessory muscles&
Rationa$e # ;iaphragmatic breathing involves contraction and rela<ation of the diaphragm&
Rationa$e -# Costal breathing can be observed by the movement of the chest upward and outward&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question
Type: MCMA
The nurse is assessing a clientFs respiratory status& (ndicators of normal respiratory status include#
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)tandard Tet: Select all that apply&
1. +upnea&
2. ,se of e<ternal intercostal muscles&
3. Suprasternal retraction&
. rthopnea&
-. Apnea&
Corre!t "ns#er: $!
Rationa$e 1# +upnea describes normal adult respirations$ !N!4 rpm depending on baseline&
Rationa$e 2# The use of e<ternal intercostal muscles is a characteristic of normal thoracic respirations&
Rationa$e 3# Suprasternal retraction$ the indrawing above the clavicles and sternum$ is not characteristic ofnormal respirations&
Rationa$e # rthopnea$ the ability to breathe only in an upright sitting or standing position$ is not characteristic
of normal respirations&
Rationa$e -# Apnea$ the cessation of breathing$ is not characteristic of normal respirations&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /
Type: MCMA
The nurse measures a clientFs respiratory rate at "4 rpm& The nurse reviews the clientFs chart and discovers the
following factors that might be causing the increase in respirations#
)tandard Tet: Select all that apply&
1. The client is febrile&
2. The client was Eust told about a poor prognosis&
3. The client has been diagnosed with increased intracranial pressure&
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. The client was Eust medicated for pain&
-. The clientFs body temperature is 967G&
Corre!t "ns#er: $!
Rationa$e 1# The client who is febrile will often have an increased respiratory rate&
Rationa$e 2# The client who is undergoing stress might have an increased respiratory rate as the body readies for
Kfight or flight&L
Rationa$e 3# The client with increased intracranial pressure will show a decrease in respiratory rate&
Rationa$e # Certain medications$ such as narcotics and analgesics$ will decrease the respiratory rate&
Rationa$e -# The client with a decreased body temperature will show a decreased respiratory rate&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question 0
Type: MCMA
0hile assessing a clientFs respirations as abnormal$ the nurse notes the following#
)tandard Tet: Select all that apply&
1. The rate of respirations
2. The depth of respirations
3. The clientFs normal breathing patterns
. The relationship of respirations to cardiovascular function
-. Bac. of sound when breathing
Corre!t "ns#er: $!$"$4
Rationa$e 1# The nurse notes the rate of respirations$ by number$ as well as terms such as tachypnic and bradypnic&
Rationa$e 2# The nurse notes the depth of the clientFs respirations by watching the movement of the chest&
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Rationa$e 3# A change in the clientFs normal breathing pattern should be noted&
Rationa$e # A client with compromised cardiovascular status is li.ely to have alterations in her respiratory
pattern$ with increased or decreased breath sounds$ respiratory rate$ or depth&
Rationa$e -# )ormal breathing is silent&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question
Type: MCMA
The nurse is e<plaining the basic physiology and significance of blood pressure to a client who has beenhospitali@ed for hypertension& (nformation that is important to discuss includes#
)tandard Tet: Select all that apply&
1. 1enous blood pressure is a measure of the force e<erted by the blood as it flows through the arteries&
2. The systolic pressure is the pressure of the blood as a result of contraction of the ventricles&
3. The diastolic blood pressure is the lower pressure that is present at all times within the arteries&
. -lood pressure is static&
-. -lood pressure is recorded as a fraction&
Corre!t "ns#er: !$"$%
Rationa$e 1# Arterial blood pressure is a measure of the force e<erted by the blood as it flows through the arteries
Rationa$e 2# The systolic pressure is the result of contraction of the ventriclesthe pressure at the height of the
blood wave&
Rationa$e 3# The diastolic pressure is the pressure when ventricles are at rest&
Rationa$e # -lood pressure is not static$ and normally changes from minute to minute&
Rationa$e -# -lood pressure is measured in millimeters of mercury$ recorded as a fraction$ with the systolic
pressure written above the diastolic pressure&
%$o&a$ Rationa$e:
*amont$ )iedringhous$ Comprehensive Nursing Care !nd +dition ,pdate Test -an.
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Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /
Type: MCMA
As the nurse assesses a clientFs blood pressure$ he understands that blood pressure is a result of#
)tandard Tet: Select all that apply&
1. The volume of blood pumped into the arteries by the heart&
2. The volume of blood pumped into the veins by the heart&
3. The compliance of the veins&
. The si@e of the arterioles&
-. The thic.ness of the blood&
Corre!t "ns#er: $4$%
Rationa$e 1#
Rationa$e 2#
Rationa$e 3#
Rationa$e #
Rationa$e -#
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /1
Type: MCMA
As the nurse teaches a group of high school students about factors affecting blood pressure$ the following non3modifiable factors are discussed#
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)tandard Tet: Select all that apply&
1. Age
2. besity
3. ;iurnal variations
. +<ercise
-. Medications
Corre!t "ns#er: $"
Rationa$e 1# Age is a non3modifiable factor8 blood pressure increases with age from the newborn to the pea. atthe onset of puberty& (n older people$ the elasticity of the arteries is decreased$ which yields elevated systolic and
diastolic pressures&
Rationa$e 2# -lood pressure is generally higher in overweight and obese people8 weight can be lost through dietand e<ercise modification&
Rationa$e 3# -lood pressure is usually lowest early in the morning$ when the metabolic rate is lowest&
Rationa$e # 'hysical activity increases the cardiac output and the blood pressure&
Rationa$e -# Many medications can increase of decrease the blood pressure$ and medications should be reviewed
if abnormal measurements are determined&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /2
Type: MCSA
The community health nurse is holding a blood pressure chec. at a community center& 0hich of the following
measurements indicates stage hypertension?
1. %:56
2. "6:
3. %4:9/
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. 6!:9/
Corre!t "ns#er: "
Rationa$e 1# This blood pressure is within normal limits$ and should be rechec.ed in year&
Rationa$e 2# This blood pressure indicates prehypertension$ and should be rechec.ed within 6N! months&
Rationa$e 3# This blood pressure indicates stage hypertension$ and should be rechec.ed within month&
Rationa$e # This blood pressure indicates a split category$ between stage and !$ and should be evaluated or
referred to a source of care within wee.&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /3
Type: MCSA
The nurse is caring for a client who has been on bedrest for several wee.s& The nurse ta.es precaution when
assisting the client to the chair due to the ris. of#
1. =ypotension&
2. =ypertension&
3. rthostatic hypertension&
. rthostatic hypotension&
Corre!t "ns#er: 4
Rationa$e 1# =ypotension is a condition where blood pressure that is below normal is combined with the presenc
of symptoms8 the information given does not support this answer
Rationa$e 2# =ypotension is a condition where blood pressure that is below normal is combined with the presencof symptoms8 the information given does not support this answer
Rationa$e 3# =ypotension is a condition where blood pressure that is below normal is combined with the presenc
of symptoms8 the information given does not support this answer
Rationa$e # =ypotension is a condition where blood pressure that is below normal is combined with the presencof symptoms8 the information given does not support this answerCognitive Bevel# Applying
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%$o&a$ Rationa$e:
Cogniti'e (e'e$: =ypotension is a condition where blood pressure that is below normal is combined with the presence of symptoms8 the information given does not support this answerCognitive Bevel# Applying
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# (mplementation
(earning ut!ome:
Question /
Type: S+I
orot.offFs sounds can be differentiated into five phases& Correlate the phase from to % with the appropriate
choice&
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. Systolic blood pressure
Choi!e 2. Sounds have a muffled$ whooshing$ swishing quality&
Choi!e 3. Sounds become crisper$ more intense&
Choi!e . Sounds become muffled$ with a soft blowing quality&
Choi!e -. ;iastolic blood pressure
Corre!t "ns#er: $!$"$4$%
Rationa$e 1# 'hase is the pressure level at which the first faint$ clear tapping or thumping sounds are heart8 thefirst tapping sound heard during deflation of the cuff is the systolic blood pressure&
Rationa$e 2# 'hase ! is the period during deflation when the sounds have a muffled$ whooshing$ or swishing
quality&
Rationa$e 3# 'hase " is the period during which the blood flows freely through an increasingly open artery andthe sounds become crisper and more intense and again assume a thumping quality$ but softer than in phase &
Rationa$e # 'hase 4 is the time when the sounds become muffled and have a soft$ blowing quality&
Rationa$e -# 'hase % is the level when the last sound is heard8 the pressure at which the last sound is heard is thediastolic blood pressure in adults&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Applying
C$ient Need: 'sychosocial (ntegrity
C$ient Need )u&:
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Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question /-
Type: MCMA
The nurse identifies factors that can cause errors in blood pressure measurement that yield higher results$ such as
)tandard Tet: Select all that apply&
1. ,se of an electronic blood pressure device&
2. ,se of an aneroid sphygmomanometer&
3. ,se of a ;oppler ultrasound stethoscope&
. A blood pressure cuff that is too small for the diameter of the clientFs arm&
-. A blood pressure cuff that is too long&
Corre!t "ns#er: $4
Rationa$e 1# *esearch indicates that automated electronic devices produce higher values than do manual
readings&
Rationa$e 2# The manual sphygmomanometer will yield the most accurate measurement&
Rationa$e 3# The use of a ;S is indicated when orot.offFs sounds are difficult to hear&
Rationa$e # (f the bladder of the blood pressure cuff is too narrow for the clientFs arm$ the blood pressure readin
will be erroneously elevated&
Rationa$e -# (f the blood pressure cuff is too long for the client$ the blood pressure reading will be erroneously
low&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analysis
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment(earning ut!ome:
Question /
Type: MCMA
The nurse is choosing the appropriate blood pressure cuff for a client& The following considerations affect thedecision#
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-. Arteriovenous fistula&
Corre!t "ns#er: !$"$4
Rationa$e 1# The client with a unilateral mastectomy should have the blood pressure measured on the unaffected
arm&
Rationa$e 2# The client with (1s in both arms should have the blood pressure measured on the thigh&
Rationa$e 3# The client with burns or trauma affecting the upper body$ including the shoulders or hands
>bilaterally$ should have the blood pressure measured on the thigh&
Rationa$e # The client with bilateral mastectomies should have the blood pressure measured on the thigh&
Rationa$e -# The client with an arteriovenous fistula should have the blood pressure measured on the unaffected
arm&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analysis
C$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome:
Question /0
Type: S+I
The nurse uses the two3step palpatory blood pressure measurement to ensure accurate results& 'lace the steps in
the appropriate order#
)tandard Tet: Clic. and drag the options below to move them up or down&
Choi!e 1. The blood pressure cuff is inflated until the brachial or radial pulse is occluded&
Choi!e 2. The nurse notes the reading$ and deflates the cuff&
Choi!e 3. The nurse waits "/N6/ seconds&
Choi!e . The cuff is inflated !/N"/ mm=g higher than number noted&
Corre!t "ns#er: $!$"$4
Rationa$e 1# The blood pressure cuff is inflated while palpating the radial or brachial pulse$ until the artery is
occluded and the pulse cannot be palpated&
Rationa$e 2# The nurse notes the reading and deflates the cuff&
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Rationa$e 3# The nurse waits "/N6/ seconds prior to reinflating cuff$ to allow blood flow to normali@e&
Rationa$e # The cuff is inflated !/N"/ mm=g higher than the number noted on palpation$ and the rest of the
procedure is the same as with the auscultatory method&
%$o&a$ Rationa$e:
Cogniti'e (e'e$: AnalysisC$ient Need: 'hysiological (ntegrity
C$ient Need )u&:
Nursing*+ntegrated Con!epts: )ursing 'rocess# Assessment
(earning ut!ome: