CRE Review.... Fundamentals || with Errorless Answers.
A, C, D- Unless the client is unstable, UAP can take initial vital signs on a newly admitted client
or a client returning from dialysis (options 1 and 3). Measurement of a client's temperature can
be delegated to UAP (option 4). The UAP may not assess, and the nurse needs to assess the
apical pulse for rhythm and rate. While the UAP can count the rate, they cannot assess for
regularity. However, remember that the UAP can do this data collection, but an assessment needs
to be completed by a registered nurse (option 2). UAP cannot be delegated vital signs for
unstable clients (option 5). correct answers Which of the following tasks can be delegated to
unlicensed assistive personnel (UAP)? Select all that apply.
A. Vital signs for a client just admitted to the floor from a nursing home
B. A client who needs an apical pulse checked prior to medication administration
C. Vital signs for a client just returned to the floor from dialysis
D. A client who needs a tympanic temperature taken
E. Blood pressure for a client whose last two BPs were 98/72 and 85/60
A- Rationale: The arm should be at the level of the heart and not above the level of the heart. An
arm at shoulder level gives an erroneously low reading. Option 2 describes the correct height for
the arm while taking blood pressure. Waiting 1 to 2 minutes before repeating an assessment
prevents an erroneously high systolic or low diastolic reading (option 3). Assessing immediately
after a meal or while a client smokes can also cause an erroneously high blood pressure, so
resting before measuring is the correct technique (option 4). correct answers The nurse is
assessing the student's skill set in taking blood pressures. Which observation, if made by the
nurse, requires intervention so that the student takes proper measurements?
A. The student nurse has the client hold his arm out from his body at shoulder level while taking
the reading.
B. The student nurse has the client place his arm at the level of the heart while taking the reading.
C. The student nurse allows 1-2 minutes between readings if unsure of the numbers.
D. The student nurse allows the client to rest after finishing eating before taking a blood
pressure.
A.-Rationale: An average pulse rate for a teenager is 75, not 100, beats per minute. An average
heart rate of 100 beats per minute would describe a child between the ages of 5 and 8. An
,average range of respirations for a newborn is 30 to 80 breaths per minute (option 2). An average
pulse range for a 1-year-old is 80 to 140 beats per minute (option 3). An average respiration rate
for an older adult is 16 breaths per minute (option 4). correct answers A nurse is teaching a group
of nursing students the differences in pulse and respiration readings across the life span. Which
statement, if made by a nursing student, indicates the need for further teaching?
A. "An average pulse rate for a teenager is 100 beats per minute."
B. "An average range of respirations for a newborn is 30 to 80 breaths per minute."
C. "An average pulse range for a 1-year-old is 80 to 140 beats per minute."
D. "An average respiration rate for an older adult is 16 breaths per minute."
C- Rationale: In hypertension stage 1, the systolic reading falls between 140 and 159 mmHg or
the diastolic reading falls between 90 and 99. A normal blood pressure reading (option 1) is a
systolic reading of less than 120 mmHg, and a diastolic reading of less than 80 mmHg. In
prehypertension (option 2), the systolic is between 120 and 139 mmHg or the diastolic is
between 80 and 89 mmHg. In hypertension stage 2 (option 4), the systolic reading is greater than
160 mmHg or the diastolic is greater than 100 mmHg. correct answers A client's blood pressure
reading is 144/96. In which classification does this blood pressure reading qualify?
A. Normal
B. Prehypertension
C. Hypertension, stage 1
D. Hypertension, stage 2
B- Rationale: Rectal thermometers provide a reliable measurement, but the presence of stool may
interfere with thermometer placement. Oral temperature readings are accessible and convenient,
but can be inaccurate if the client has just ingested hot or cold food or fluid or been smoking
(option 1). A temporal artery measurement is safe, noninvasive, and very fast (option 3). A
tympanic membrane measurement is readily accessible, reflects the core temperature, and is very
fast as well (option 4). correct answers A nurse is considering the different sites for body
temperature measurement. Which statement regarding site choice for body temperature
measurement requires further instruction or clarification?
A. "Although oral temperatures are accessible and convenient, they are inaccurate if the client
has just smoked or eaten."
B. "Rectal thermometers are a reliable measurement even in the presence of stool."
, C. "Temporal artery measurements are safe, noninvasive, and very fast."
D. "Tympanic membrane readings are readily accessible, reflect the core temperature, and are
very fast."
DRationale: In this instance, the nurse needs an accurate assessment of the pulse rate and rhythm
before administering a medication that affects heart rate, digoxin, so an apical pulse needs to be
auscultated for a full minute prior to administration because it is the most accurate means of
assessing the pulse. Options 1, 2, and 3 are incorrect because peripheral pulse assessment is less
accurate than apical pulse assessment.
- correct answers The nurse is preparing to take a pulse on a client who is receiving digoxin
(Lanoxin), which affects the heart rate. This assessment needs to be completed prior to the
medication administration. Which skill is correct when assessing the pulse of this client?
A. A radial pulse taken for 15 seconds
B. A femoral pulse taken for 30 seconds
C. A carotid pulse taken for a full minute
D. An apical pulse taken for a full minute
C- Rationale: The symptoms provided describe tachypnea or quick shallow breaths; intercostal
retractions, or indrawing between the ribs; hemoptysis, or the presence of blood in the sputum;
and stridor, or a shrill, harsh sound heard during inspiration with laryngeal obstruction.
Bradypnea is abnormally slow respirations (options 1 and 2). Substernal retractions are
indrawing below the xiphoid process (options 2 and 4), and wheezing is a high-pitched whistling
sound (option 4). correct answers A client presents with quick shallow breaths indrawing
between the ribs, and bloody sputum. Upon auscultation, the client is found to have a shrill harsh
sound heard during inspiration. Which assessments most accurately describe this client?
A. Bradypnea, intercostal retractions, productive cough, and wheezing
B. Bradypnea, substernal retractions, hemoptysis, and stridor
C. Tachypnea, intercostal retractions, hemoptysis, and stridor
D. Tachypnea, substernal retractions, productive cough, and wheezing
A, C, D- Unless the client is unstable, UAP can take initial vital signs on a newly admitted client
or a client returning from dialysis (options 1 and 3). Measurement of a client's temperature can
be delegated to UAP (option 4). The UAP may not assess, and the nurse needs to assess the
apical pulse for rhythm and rate. While the UAP can count the rate, they cannot assess for
regularity. However, remember that the UAP can do this data collection, but an assessment needs
to be completed by a registered nurse (option 2). UAP cannot be delegated vital signs for
unstable clients (option 5). correct answers Which of the following tasks can be delegated to
unlicensed assistive personnel (UAP)? Select all that apply.
A. Vital signs for a client just admitted to the floor from a nursing home
B. A client who needs an apical pulse checked prior to medication administration
C. Vital signs for a client just returned to the floor from dialysis
D. A client who needs a tympanic temperature taken
E. Blood pressure for a client whose last two BPs were 98/72 and 85/60
A- Rationale: The arm should be at the level of the heart and not above the level of the heart. An
arm at shoulder level gives an erroneously low reading. Option 2 describes the correct height for
the arm while taking blood pressure. Waiting 1 to 2 minutes before repeating an assessment
prevents an erroneously high systolic or low diastolic reading (option 3). Assessing immediately
after a meal or while a client smokes can also cause an erroneously high blood pressure, so
resting before measuring is the correct technique (option 4). correct answers The nurse is
assessing the student's skill set in taking blood pressures. Which observation, if made by the
nurse, requires intervention so that the student takes proper measurements?
A. The student nurse has the client hold his arm out from his body at shoulder level while taking
the reading.
B. The student nurse has the client place his arm at the level of the heart while taking the reading.
C. The student nurse allows 1-2 minutes between readings if unsure of the numbers.
D. The student nurse allows the client to rest after finishing eating before taking a blood
pressure.
A.-Rationale: An average pulse rate for a teenager is 75, not 100, beats per minute. An average
heart rate of 100 beats per minute would describe a child between the ages of 5 and 8. An
,average range of respirations for a newborn is 30 to 80 breaths per minute (option 2). An average
pulse range for a 1-year-old is 80 to 140 beats per minute (option 3). An average respiration rate
for an older adult is 16 breaths per minute (option 4). correct answers A nurse is teaching a group
of nursing students the differences in pulse and respiration readings across the life span. Which
statement, if made by a nursing student, indicates the need for further teaching?
A. "An average pulse rate for a teenager is 100 beats per minute."
B. "An average range of respirations for a newborn is 30 to 80 breaths per minute."
C. "An average pulse range for a 1-year-old is 80 to 140 beats per minute."
D. "An average respiration rate for an older adult is 16 breaths per minute."
C- Rationale: In hypertension stage 1, the systolic reading falls between 140 and 159 mmHg or
the diastolic reading falls between 90 and 99. A normal blood pressure reading (option 1) is a
systolic reading of less than 120 mmHg, and a diastolic reading of less than 80 mmHg. In
prehypertension (option 2), the systolic is between 120 and 139 mmHg or the diastolic is
between 80 and 89 mmHg. In hypertension stage 2 (option 4), the systolic reading is greater than
160 mmHg or the diastolic is greater than 100 mmHg. correct answers A client's blood pressure
reading is 144/96. In which classification does this blood pressure reading qualify?
A. Normal
B. Prehypertension
C. Hypertension, stage 1
D. Hypertension, stage 2
B- Rationale: Rectal thermometers provide a reliable measurement, but the presence of stool may
interfere with thermometer placement. Oral temperature readings are accessible and convenient,
but can be inaccurate if the client has just ingested hot or cold food or fluid or been smoking
(option 1). A temporal artery measurement is safe, noninvasive, and very fast (option 3). A
tympanic membrane measurement is readily accessible, reflects the core temperature, and is very
fast as well (option 4). correct answers A nurse is considering the different sites for body
temperature measurement. Which statement regarding site choice for body temperature
measurement requires further instruction or clarification?
A. "Although oral temperatures are accessible and convenient, they are inaccurate if the client
has just smoked or eaten."
B. "Rectal thermometers are a reliable measurement even in the presence of stool."
, C. "Temporal artery measurements are safe, noninvasive, and very fast."
D. "Tympanic membrane readings are readily accessible, reflect the core temperature, and are
very fast."
DRationale: In this instance, the nurse needs an accurate assessment of the pulse rate and rhythm
before administering a medication that affects heart rate, digoxin, so an apical pulse needs to be
auscultated for a full minute prior to administration because it is the most accurate means of
assessing the pulse. Options 1, 2, and 3 are incorrect because peripheral pulse assessment is less
accurate than apical pulse assessment.
- correct answers The nurse is preparing to take a pulse on a client who is receiving digoxin
(Lanoxin), which affects the heart rate. This assessment needs to be completed prior to the
medication administration. Which skill is correct when assessing the pulse of this client?
A. A radial pulse taken for 15 seconds
B. A femoral pulse taken for 30 seconds
C. A carotid pulse taken for a full minute
D. An apical pulse taken for a full minute
C- Rationale: The symptoms provided describe tachypnea or quick shallow breaths; intercostal
retractions, or indrawing between the ribs; hemoptysis, or the presence of blood in the sputum;
and stridor, or a shrill, harsh sound heard during inspiration with laryngeal obstruction.
Bradypnea is abnormally slow respirations (options 1 and 2). Substernal retractions are
indrawing below the xiphoid process (options 2 and 4), and wheezing is a high-pitched whistling
sound (option 4). correct answers A client presents with quick shallow breaths indrawing
between the ribs, and bloody sputum. Upon auscultation, the client is found to have a shrill harsh
sound heard during inspiration. Which assessments most accurately describe this client?
A. Bradypnea, intercostal retractions, productive cough, and wheezing
B. Bradypnea, substernal retractions, hemoptysis, and stridor
C. Tachypnea, intercostal retractions, hemoptysis, and stridor
D. Tachypnea, substernal retractions, productive cough, and wheezing
