1. Which step must be taken to ensure accurate measurement of a patient’s daily weight?

1. Weigh the patient at a different time each day.
2. Ask the patient to void before he or she is weighed.
3. Ask the patient to list all food and beverages consumed since the last weight measurement was taken.
4. Weigh the patient using two different scales, and compare the weights.

2. What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient’s radial pulse?

1. Place the patient in the lateral (side-lying) position before measuring the pulse.
2. Apply gloves with each patient before measuring the pulse.
3. Document whether the patient’s pulse is bounding or has diminished.
4. Palpate the patient’s inner wrist on the thumb side with the fingertips of your two middle fingers.

3. The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?

1. Follow your regular healthy diet.
2. Limit physical activity.
3. Ensure an adequate daily intake of sodium and fat.
4. Ensure that your diet has an adequate daily intake of calcium.

4. What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient’s pain?

1. “Let me know at least 30 minutes before you transport her so I can administer her pain medication.”
2. “Be sure to keep the room temperature high and the TV on at all times.”
3. “Be sure to tell me if you notice grimacing, guarding, or any unusual behavior.”
4. “I’ve given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.”

5. Which action would best assess the effect of exercise on a patient’s radial pulse measurement?

1. Measuring the patient’s radial pulse before and after exercise
2. Assessing the patient’s radial pulse 30 minutes after exercise
3. Comparing the patient’s radial and apical pulses after exercise
4. Comparing the patient’s pre-exercise radial and post-exercise apical pulses

6. Which observation indicates that a patient’s pain medication has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention?

1. The patient is seen quietly reading a magazine.
2. The patient rates her current pain as 3 out of 10 on the pain rating scale.
3. The patient is overheard telling her family that she is “feeling better today.”
4. The patient is observed sleeping, with a respiratory rate assessed at 18/minute, compared with 22/minute before the intervention.

7. When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?

1. The number of inspirations per minute.
2. The number of expirations per minute.
3. The number of sighs per minute.
4. The number of inspirations and expirations per minute.

8. The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement?

1. Place the sensor on the ear.
2. Place the sensor on the bridge of the nose.
3. Place the sensor on a finger.
4. Use a disposable tape-on sensor.

9. During the admissions process, the nurse initially assesses the patient’s radial pulse primarily for what purpose?

1. Assessment of peripheral blood perfusion
2. Establishment of a baseline as part of the patient’s vital signs
3. Assessment of the patient’s cardiovascular disease risk
4. Determination of oxygen saturation

10. A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient?

1. Repainting her new apartment
2. Lifting moving boxes on and off of a truck
3. Performing neck, back, and shoulder exercises prescribed by a physical therapist
4. Performing yoga exercises from the patient’s favorite set of videotapes

11. What should the nurse do when a pulse deficit is suspected?

1. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.
2. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.
3. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute.
4. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.

12. Which action would take priority if a patient’s apical pulse has an irregular rhythm?

1. Reassess the pulse for 1 full minute.
2. Assess the patient’s peripheral pulses.
3. Wait 5 minutes, and then reassess the apical pulse.
4. Review documentation regarding an irregular rhythm.

13. What is the nurse’s priority action if a patient’s radial pulse has an irregular rhythm?

1. Reassess the pulse for 1 full minute.
2. Assess the patient for a pulse deficit.
3. Wait 5 minutes, and then reassess the pulse.
4. Review documentation regarding an irregular rhythm.

14. Which of the following is contraindicated with taking a rectal temperature measurement?

1. Patient requires assistance to move to a side-lying position.
2. Patient has painful and swollen hemorrhoids.
3. Patient is incontinent of urine.
4. The last temperature recorded was 0.2° F above baseline.

15. The nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?

1. Assess the pulse for a full 60 seconds before assessing respiration.
2. Encourage the patient to rest for 10 minutes before assessing respiration.
3. Compare the postexercise respiratory rate with his baseline findings.
4. Compare the postexercise findings with the previous at-rest findings.

16. What would cause the nurse to delay the assessment of a patient’s blood pressure?

1. Patient is resting in bed, reading a book
2. Patient received medication within the last 10 minutes
3. Patient is visiting with family
4. Patient has just finished having a cigarette

17. You have the following information:
  Oral temperature—36.8° C;
  Radial Pulse—112 weak, thready;
  Apical pulse—117 regular;
  Respirations—24 regular;
  Blood Pressure—104/56 right arm;
  Blood Pressure—102/50 left arm.
What is the pulse deficit?

1. 2
2. 5
3. 6
4. 48

18. Which of the following is a risk factor for decreased oxygen saturation level in a patient?

1. Chest wall injury
2. Restlessness
3. Hypotension
4. Prescribed bronchodilators

19. The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?

1. Measuring the patient’s apical pulse before and after crying
2. Assessing the patient’s apical pulse 30 minutes after crying
3. Measuring the patient’s pulse deficit after crying
4. Comparing the patient’s post-crying apical pulse rate with her baseline or previous rate.

20. Which of the following is an early manifestation of decreased cardiac output?

1. Fatigue
2. Substernal pain
3. Nail bed cyanosis
4. Shortness of breath

21. Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?

1. “The patient’s apical pulse is recorded as you asked.”
2. “The apical pulse is more difficult to hear when the patient is sitting up.”
3. “The apical pulse is usually slower in the morning than it is in the afternoon.”
4. “The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom.”

22. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP’s last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings?

1. The blood pressure cuff is too wide for arm circumference.
2. The bladder was deflated too slowly.
3. The patient’s arm was not supported while the measurement was taken.
4. The blood pressure cuff was not wrapped evenly around the arm.

23. The nurse is planning to measure a patient’s blood pressure. What does the systolic measurement represent?

1. Minimal pressure on the arterial walls
2. The pressure exerted against the arterial wall.
3. The change in pressure from a lying to a sitting position
4. The last sound heard when measuring the blood pressure

24. On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?

1. Count breaths for 10 seconds and multiply by 6.
2. Count breaths for 15 seconds and multiply by 4.
3. Count breaths for 30 seconds and multiply by 2.
4. Count breaths for 60 seconds.

25. What is the primary purpose of initially assessing an apical pulse?

1. Assessment of the patient’s cardiac function
2. Establishment of a baseline as part of the patient’s vital signs
3. Assessment of the patient’s risk for cardiovascular disease
4. Determination of oxygen saturation

26. During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?

1. Stop the assessment.
2. Stop the assessment, and multiply the number 8 by 2.
3. Stop the assessment, and multiply the number 8 by 6.
4. Continue to count the patient's breaths for a full 60 seconds.

27. What would the nurse do to prevent the spread of infection when assessing a patient’s blood pressure?

1. Wear gloves.
2. Avoid using an arm in which an intravenous catheter has been inserted.
3. Clean the stethoscope with alcohol before and after using it.
4. Inflate the cuff 30 mm higher than the expected systolic pressure.

28. For which patient would the nurse instruct nursing assistive personnel (NAP) to weigh a patient with a bed scale?

1. Patient with an ostomy device
2. Patient with chronic renal failure who receives hemodialysis three times a week
3. Patient who is using a walker after knee replacement surgery
4. Patient who has heart failure and a consequent inability to bear weight

29. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take?

1. Do not delegate vital signs to the NAP.
2. Delegate only temperature and respiratory rate to the NAP.
3. Report the NAP to your supervisor.
4. Observe the NAP as she obtains a blood pressure and pulse on a patient.

30. Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to tympanic temperature assessment?

1. Leave the probe in place until the reading is complete.
2. Put on a new disposable probe cover for each patient.
3. Gently tug the pinna backward, up, and out before inserting the probe.
4. Check for any impacted cerumen in the ear.

31. What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?

1. Place the patient in the Fowler’s position.
2. Wear sterile gloves during the process.
3. Insert the probe in the direction of the knees.
4. Use the probe with the red tip.

32. Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?

1. Take the patient's temperature while counting the respiratory rate.
2. Assess respiration after measuring the pulse.
3. Assess respiration after taking the blood pressure.
4. Assess respiration before measuring the blood pressure.

33. When preparing to measure the height and weight of a newly admitted patient, why would the nurse ask about the patient’s ability to stand?

1. To determine if a wheelchair should be requested
2. To determine if the patient is steady enough to stand without assistance
3. To determines if a bed scale must be obtained to measure the patient’s weight
4. To establish how much help the patient will need with personal care

34. What should the nurse do if the patient’s blood pressure is not within normal limits?

1. Review the blood pressure readings in the patient’s record.
2. Assess for proper cuff size and arm positioning.
3. Promptly report the assessment data to the nurse in charge or to the health care provider.
4. Encourage the patient to rest quietly in bed for 30 minutes, and then retake the blood pressure.

35. The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw?

1. It is likely the patient is a drug seeker and has little or no pain.
2. The patient’s problem is more mental than physical.
3. The absence of physiological signs and symptoms is associated with chronic pain.
4. The patient’s pain cannot be accurately assessed until the patient has been treated for anxiety.

36. The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?

1. Minimize the effect of anxiety
2. Distract the patient
3. Listen for the second and third Korotkoff sounds
4. Confirm that the cuff was applied correctly

37. A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing facility. The patient is usually weighed in street clothing and socks, with his shoes off. The patient is currently wearing street clothing with shoes and socks. What will the NAP do to ensure that the patient’s weight is correctly measured?

1. Take off the patient’s street clothing.
2. Take off the patient’s shoes, but leave his socks on.
3. Take off the patient’s shoes and socks, and put on slippers.
4. Take off the patient’s street clothing and put on a hospital gown and nonskid socks.

38. As the nurse is conducting an admission interview, the patient states, “I’ve lost 30 pounds over the last 4 months.” Which question might the nurse ask to determine if the weight loss was intentional or unintentional?

1. “Is your health care provider aware of this weight loss?”
2. “Has your weight fluctuated like this before?”
3. “Have you been following a specific diet?”
4. “Is it easy for you to lose weight?”

39. What is the major health problem resulting from a pulse deficit?

1. Bradycardia
2. Activity intolerance
3. Decreased cardiac output
4. Impaired tissue perfusion

40. Which action should the nurse perform after identifying a pulse deficit?

1. Reassess the apical-radial pulse in 5 minutes.
2. Assess the patient for signs of decreased cardiac output.
3. Notify the primary health care provider of the pulse deficit.
4. Initiate interventions directed toward managing the patient’s symptoms.

41. What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient’s oxygen saturation level?

1. “Do not use the fingers if her nails are polished.”
2. “I’ve checked her capillary refill, and it’s acceptable in both her hands and feet.”
3. “Please review the patient’s previously documented pulse oximetry readings for the site used.”
4. “Ask the patient to keep her finger motionless while you are monitoring her oxygen saturation.”

42. Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6° F?

1. Assess for physical aches.
2. Assess skin temperature by touching the forehead.
3. Assess oral temperature 30 minutes after the agent is administered.
4. Assess skin color for signs of fever-related flushing.

43. What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient’s apical pulse?

1. Document the patient’s pulse rate and rhythm.
2. Place the patient in the right lateral position before measuring the apical pulse.
3. Review the patient’s previous apical pulse measurements.
4. Place your stethoscope at the fifth intercostal space over the left midclavicular line.

44. The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?

1. Reassess the oxygen saturation in a different location.
2. Promptly report the assessment data to the charge nurse.
3. Encourage the patient to rest quietly in bed for 30 minutes.
4. Ask the patient whether he or she is having trouble breathing.

45. Inadequate oxygenation to the body will cause the radial pulse to become:

1. Tachycardic
2. Bradycardic
3. Irregular
4. Bounding

46. A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits?

1. Low of 85% and high of 100%
2. Low of 80% and high of 100%
3. Low of 75% and high of 90%
4. Low of 82% and high of 95%

47. The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?

1. Blood pressure cuff is too wide
2. Blood pressure cuff is too loose around the arm
3. Taking the blood pressure in an arm into which intravenous fluids are infusing
4. Arm is positioned above the level of the heart

48. Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?

1. An accurate temperature reading is obtained with moisture on the forehead.
2. Put on a disposable sensor cover before taking the temporal artery temperature.
3. Place the sensor flush on the patient’s forehead.
4. Obtain the temperature reading on the lower neck.

49. Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?

1. Use the left arm to take the blood pressure.
2. Use the right arm to take the blood pressure.
3. Do not take the blood pressure.
4. Use a lower extremity to take the blood pressure.

50. A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain?

1. The patient rates his pain a 7 on a scale of 0 to 10.
2. The patient winces and guards the area as the nurse gently palpates the abdomen.
3. The patient is having trouble sleeping and has become irritable.
4. The patient is moaning softly and frowning, with a pinched expression on his face.