NURS100/ NURS 100 Assessment 1 V2 | Fundamentals of Nursing | WCU | Latest 2026–2027 Exam Questions & Answers | Verified Solutions | Grade A

NURS100/ NURS100 Assessment 1 V2 | Fundamentals of Nursing | WCU | Latest 2026–2027 Exam Questions & Answers | Verified Solutions | Grade A Q: A nurse is caring for a patient with Clostridium difficile infection (CDI). Which of the following actions is most appropriate to prevent the spread of infection? A. Use an alcohol-based hand sanitizer after providing care B. Wear gloves when entering the patient's room C. Disinfect hands with soap and water only if visibly soiled D. Place the patient in a room with a positive airflow system B. Wear gloves when entering the patient's room Q: A nurse is about to perform wound care on a patient with Methicillin-resistant Staphylococcus aureus (MRSA). What personal protective equipment (PPE) should the nurse wear? A. Gloves and surgical mask B. Gloves, gown, and surgical mask C. Gloves and gown D. Gloves, gown, and N95 respirator C. Gloves and gown Q: Which of the following patients requires contact precautions? A. A patient with tuberculosis B. A patient with varicella (chickenpox) C. A patient with an infected decubitus ulcer with copious drainage D. A patient with bacterial meningitis C. A patient with an infected decubitus ulcer with copious drainage Q: A nurse is educating a patient's family on the proper use of contact precautions at home. Which statement by the family member indicates a need for further teaching? A. "We should wear gloves when touching any of the patient's wounds or handling soiled linens." B. "We can use hand sanitizer after removing gloves if our hands are not visibly soiled." C. "It is important to wear a gown when providing care to avoid contact with body fluids." D. "We should avoid sharing personal items like towels and utensils with the patient." B. "We can use hand sanitizer after removing gloves if our hands are not visibly soiled." Q: A nurse is caring for a patient diagnosed with influenza. Which of the following actions should the nurse take to adhere to droplet precautions? A. Wear an N95 respirator when entering the patient's room B. Place the patient in a private room with negative pressure C. Wear a surgical mask within 3 feet of the patient D. Keep the door to the patient's room closed at all times C. Wear a surgical mask within 3 feet of the patient Q: Which of the following illnesses requires droplet precautions? A. Measles B. Tuberculosis C. Pertussis D. Varicella (chickenpox) C. Pertussis Q: A nurse is preparing to transport a patient with meningococcal meningitis to the radiology department. Which action is appropriate to prevent the spread of infection? A. The patient should wear a surgical mask during transport B. The patient should wear an N95 respirator during transport C. No special precautions are needed during transport D. The nurse should wear a gown and gloves during transport A. The patient should wear a surgical mask during transport Q: A nurse is teaching a new staff member about droplet precautions. Which of the following statements by the new staff member indicates a correct understanding? A. "Droplet precautions are necessary for patients with infections that can travel more than 6 feet through the air." B. "I should wear a surgical mask when I am within 3 feet of a patient on droplet precautions." C. "Droplet precautions require placing the patient in a negative pressure room." D. "Hand hygiene is not as important with droplet precautions as it is with contact precautions." B. "I should wear a surgical mask when I am within 3 feet of a patient on droplet precautions." Q: A nurse is assigned to care for a patient with active tuberculosis. Which of the following actions is most appropriate to ensure proper infection control? A. Place the patient in a private room with the door closed B. Use a surgical mask when entering the patient's room C. Place the patient in a negative pressure room D. Wear gloves and a gown when entering the patient's room C. Place the patient in a negative pressure room Q: Which of the following diseases requires airborne precautions? A. Influenza B. Rubella C. Chickenpox (varicella) D. Methicillin-resistant Staphylococcus aureus (MRSA) C. Chickenpox (varicella) Q: A nurse is preparing to enter the room of a patient with confirmed measles. What personal protective equipment (PPE) should the nurse use? A. Surgical mask B. N95 respirator C. Gown and gloves D. Surgical mask and face shield B. N95 respirator Q: A nurse is teaching a new staff member about airborne precautions. Which statement by the staff member indicates a need for further education? A. "I should wear an N95 respirator when caring for a patient with tuberculosis." B. "Patients requiring airborne precautions should be placed in a room with negative airflow." C. "It's okay to leave the door open if the patient is wearing a mask." D. "Hand hygiene is crucial after removing personal protective equipment." C. "It's okay to leave the door open if the patient is wearing a mask." Q: A nurse is assessing the radial pulse of a patient. Which of the following actions should the nurse take to ensure an accurate reading? A. Use the thumb to palpate the radial artery B. Apply firm pressure to feel the pulse C. Count the pulse for 15 seconds and multiply by four D. Place two to three fingers over the radial artery D. Place two to three fingers over the radial artery Q: A nurse is taking an apical pulse on a patient with an irregular heart rate. What is the most appropriate technique for the nurse to use? A. Palpate the pulse for 30 seconds and multiply by two B. Count the pulse for a full minute using a stethoscope C. Use the radial pulse for accuracy D. Estimate the pulse rate based on the patient's history B. Count the pulse for a full minute using a stethoscope Q: A nurse needs to measure the pulse rate of a patient with a known bradycardia. Which of the following sites is the most appropriate for accurate assessment? A. Radial artery B. Carotid artery C. Apical pulse D. Brachial artery C. Apical pulse Q: While assessing the pulse of a patient, the nurse notes the rhythm is irregular. What is the nurse's best next step? A. Continue to count the pulse for 15 seconds and multiply by four B. Switch to counting the pulse at the carotid artery C. Count the pulse for a full minute D. Document the finding and notify the healthcare provider immediately C. Count the pulse for a full minute Q: A nurse is preparing to measure a patient's blood pressure manually. Which of the following actions should the nurse take to ensure an accurate reading? A. Position the patient's arm above heart level B. Use a cuff that is 40% of the arm's circumference C. Inflate the cuff rapidly to 100 mmHg D. Have the patient hold their breath during the measurement B. Use a cuff that is 40% of the arm's circumference Q: A nurse is teaching a patient about taking their blood pressure at home. Which statement by the patient indicates a need for further teaching? A. "I should sit with my feet flat on the floor when taking my blood pressure." B. "I should take my blood pressure in the morning and again before bedtime." C. "I can talk to my family while taking my blood pressure." D. "I should use the same arm each time I measure my blood pressure." C. "I can talk to my family while taking my blood pressure." Q: The nurse measures a patient's blood pressure and obtains a reading of 150/90 mmHg. What should the nurse do next? A. Record the reading and take it again in 30 minutes B. Immediately notify the healthcare provider C. Ask the patient if they have taken any antihypertensive medications D. Reassess the blood pressure after the patient rests for 5 minutes Q: A nurse is taking blood pressure on a patient and hears faint tapping sounds that disappear and then reappear as she deflates the cuff. What is the most likely cause of this phenomenon? A. The patient is experiencing arrhythmia B. The cuff size is too large C. The nurse is hearing an auscultatory gap D. The stethoscope diaphragm is incorrectly placed C. The nurse is hearing an auscultatory gap Q: A nurse is assessing a patient's respiratory rate. Which of the following techniques should the nurse use to ensure an accurate measurement? A. Ask the patient to breathe normally and count for 15 seconds B. Count the respiratory rate immediately after taking the radial pulse C. Inform the patient that their breathing will be monitored D. Measure the respiratory rate after the patient has been walking B. Count the respiratory rate immediately after taking the radial pulse Q: The nurse notes that a patient's respiratory rate is 8 breaths per minute. Which of the following terms should the nurse use to document this finding? A. Tachypnea B. Apnea C. Eupnea D. Bradypnea D. Bradypnea Q: Which of the following factors can cause an increase in a patient's respiratory rate? A. Hypothermia B. Narcotic analgesics C. Pain D. Sleep C. Pain Q: A nurse is teaching a student how to assess the respiratory rate of a patient. Which statement by the student indicates a need for further education? A. "I should count each rise and fall of the chest as one breath." B. "It is okay to assess the respiratory rate while the patient is talking." C. "I should observe the patient's breathing without them knowing I am counting." D. "I should count the respiratory rate for a full minute if it is irregular." B. "It is okay to assess the respiratory rate while the patient is talking." Q: A nurse is assessing a patient's oxygen saturation using a pulse oximeter. Which of the following factors could lead to an inaccurate reading? A. The patient is wearing nail polish on their fingers B. The pulse oximeter probe is placed on the earlobe C. The patient is calm and at rest D. The room lighting is dim A. The patient is wearing nail polish on their fingers Q: A nurse is monitoring a patient with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation reading of 88%. What is the most appropriate action for the nurse to take? A. Increase the oxygen flow rate immediately B. Reassess the oxygen saturation using a different finger C. Document the reading and continue to monitor D. Notify the healthcare provider and assess the patient's condition D. Notify the healthcare provider and assess the patient's condition Q: A nurse is teaching a patient about the use of a pulse oximeter at home. Which statement by the patient indicates a correct understanding? A. "I should place the probe on my toe for an accurate reading." B. "I can use the pulse oximeter while my hand is cold." C. "I need to keep my hand still while the pulse oximeter is taking the reading." D. "I should remove any jewelry from my hand before using the pulse oximeter." C. "I need to keep my hand still while the pulse oximeter is taking the reading." A nurse is assessing a patient's oxygen saturation and finds a reading of 95%. What should the nurse do next? A. Continue to monitor the patient and document the reading B. Assess the patient's respiratory rate and effort C. Increase the oxygen flow rate to improve the saturation D. Contact the healthcare provider immediately A. Continue to monitor the patient and document the reading A nurse is assessing the heart rate of a well-trained athlete. What is the most likely characteristic of their heart rate? A. Tachycardia with a resting heart rate over 100 beats per minute B. Bradycardia with a resting heart rate below 60 beats per minute C. Normal resting heart rate of 70-90 beats per minute D. Irregular heart rate due to high levels of physical activity B. Bradycardia with a resting heart rate below 60 beats per minute A nurse is assessing the heart rate of an elderly patient. Which of the following is a normal consideration for heart rate in this population? A. A resting heart rate significantly lower than younger adults B. A resting heart rate consistently above 100 beats per minute C. A normal resting heart rate range of 60-100 beats per minute D. A resting heart rate that is irregular and difficult to assess C. A normal resting heart rate range of 60-100 beats per minute A nurse is assessing the heart rate of a patient experiencing acute anxiety. What change in heart rate might the nurse expect? A. Bradycardia due to relaxation B. Tachycardia due to increased sympathetic nervous system activity C. Normal heart rate due to the body's adaptation D. Irregular heart rate due to fluctuating anxiety levels B. Tachycardia due to increased sympathetic nervous system activity A nurse notices that a patient's blood pressure drops from 140/85 mmHg to 90/60 mmHg upon standing. What is the most likely cause of this change? A. Orthostatic hypotension B. Hypertension C. Acute myocardial infarction D. Dehydration A. Orthostatic hypotension A nurse is assessing a patient with a history of chronic kidney disease who presents with a blood pressure of 160/100 mmHg. What is the most appropriate intervention? A. Continue to monitor the blood pressure without immediate action B. Encourage the patient to reduce salt intake and increase fluid intake C. Consult with a healthcare provider about possible antihypertensive medications D. Reassess the blood pressure in 15 minutes to check for accuracy C. Consult with a healthcare provider about possible antihypertensive medications A nurse measures a patient's blood pressure and finds it to be consistently high during multiple readings. What is the most important next step in management? A. Recheck the blood pressure at different times of the day B. Advise the patient to increase their physical activity C. Assess the patient for signs of target organ damage D. Suggest the patient reduce their caffeine intake C. Assess the patient for signs of target organ damage A nurse observes that a patient's blood pressure has increased significantly after starting a new medication. What should the nurse do first? A. Document the change in blood pressure and continue monitoring B. Discontinue the medication and notify the healthcare provider C. Recheck the blood pressure to confirm the increase D. Adjust the dosage of the medication based on the increase C. Recheck the blood pressure to confirm the increase A nurse is using an electronic thermometer to measure a patient's oral temperature. Which of the following actions should the nurse take to ensure an accurate reading? A. Place the thermometer under the patient's tongue and ask them to breathe through their nose B. Wait 5 minutes after the patient has had a hot or cold drink before taking the temperature C. Use a new disposable probe cover for each measurement D. Hold the thermometer in place with the patient's mouth closed for 30 seconds B. Wait 5 minutes after the patient has had a hot or cold drink before taking the temperature A nurse is assessing a patient's temperature using a tympanic thermometer. What is the most important step to ensure accurate results? A. Pull the ear lobe down and back for adults B. Insert the thermometer deeply into the ear canal C. Ensure the patient has been lying still for 10 minutes D. Position the thermometer so that it points toward the patient's ear canal D. Position the thermometer so that it points toward the patient's ear canal A nurse is using a rectal thermometer to measure a patient's temperature. Which action should the nurse take to ensure an accurate and safe measurement? A. Lubricate the thermometer before insertion B. Insert the thermometer 2-3 inches into the rectum C. Leave the thermometer in place for 10 minutes D. Use the same thermometer for oral and rectal measurements A. Lubricate the thermometer before insertion A nurse is measuring a patient's axillary temperature. What should the nurse do to ensure the accuracy of the reading? A. Place the thermometer under the patient's arm and hold it tightly against the skin B. Wait 2 minutes after placing the thermometer before taking the reading C. Ensure the patient's arm is elevated during the measurement D. Use an oral thermometer instead of an axillary thermometer for better accuracy A. Place the thermometer under the patient's arm and hold it tightly against the skin A nurse is monitoring a patient who has just started on a new medication. The patient's blood pressure has increased from 120/80 mmHg to 160/95 mmHg. What is the most appropriate initial action for the nurse to take? A. Document the change and continue to monitor the patient B. Discontinue the medication immediately and notify the healthcare provider C. Recheck the blood pressure to confirm the increase D. Administer antihypertensive medication as per protocol C. Recheck the blood pressure to confirm the increase A nurse notes that a patient's respiratory rate has increased from 14 breaths per minute to 28 breaths per minute. What might be a likely cause for this change? A. Dehydration B. Hyperventilation C. Bradycardia D. Hypothermia B. Hyperventilation A patient's heart rate changes from 80 beats per minute to 120 beats per minute while experiencing chest pain. What should the nurse assess next? A. The patient's blood pressure B. The patient's temperature C. The patient's blood glucose level D. The patient's oxygen saturation A. The patient's blood pressure A nurse observes that a patient's temperature has decreased from 101.5°F to 98.2°F after receiving antipyretic medication. What is the best interpretation of this finding? A. The patient is likely experiencing a normal response to the medication B. The patient may have developed an infection C. The patient's temperature was inaccurately measured initially D. The antipyretic medication is causing an adverse effect A. The patient is likely experiencing a normal response to the medication A nurse is assessing a patient with acute pain. Which of the following characteristics is most likely to describe the patient's pain? A. Persistent and lasting for months B. Associated with a specific injury or event C. Intensity that is generally stable over time D. Often described as dull or aching B. Associated with a specific injury or event A patient reports that their pain has been present for over six months and is affecting their daily life. What type of pain is this patient most likely experiencing? A. Acute pain B. Referred pain C. Chronic pain D. Neuropathic pain C. Chronic pain A nurse is educating a patient about managing chronic pain. Which of the following strategies should the nurse include in the education? A. Focus solely on medication for pain relief B. Use pain relief strategies intermittently as needed C. Incorporate non-pharmacologic methods such as physical therapy and relaxation techniques D. Ignore the pain and continue normal activities without modifications C. Incorporate non-pharmacologic methods such as physical therapy and relaxation techniques A nurse is evaluating a patient who describes their pain as "sharp and sudden," and it began after a recent injury. What is the most appropriate classification of this pain? A. Chronic pain B. Acute pain C. Neuropathic pain D. Breakthrough pain B. Acute pain A nurse is using the Wong-Baker FACES Pain Rating Scale to assess a child's pain level. How should the nurse instruct the child to use this scale? A. Point to the face that best describes how much pain they feel, from "no pain" to "very much pain" B. Describe their pain intensity in words ranging from "mild" to "severe" C. Rate their pain on a scale from 1 to 10, where 10 is the worst pain D. Indicate if their pain is constant or intermittent A. Point to the face that best describes how much pain they feel, from "no pain" to "very much pain" A nurse is assessing pain in a patient using the Numeric Pain Rating Scale. What is the primary advantage of using this scale? A. It is suitable for patients who have difficulty understanding visual images B. It provides a quick, easy-to-understand measure of pain intensity C. It is effective for assessing pain in non-verbal patients D. It measures pain by assessing physiological changes B. It provides a quick, easy-to-understand measure of pain intensity A nurse is using the Brief Pain Inventory (BPI) to assess a patient's pain. What type of information does this tool primarily gather? A. The location and description of the pain B. The pain's intensity and its impact on daily functioning C. The patient's past medical history related to pain D. The effectiveness of pain medications used B. The pain's intensity and its impact on daily functioning A nurse is assessing a patient's pain using the McGill Pain Questionnaire. What type of information does this tool provide? A. A numerical rating of pain intensity B. The patient's verbal description of the pain and its characteristics C. A visual representation of pain using faces D. A comparison of pain before and after treatment B. The patient's verbal description of the pain and its characteristics A nurse is using the CRIES Pain Scale to assess pain in a postoperative infant. What does the CRIES scale primarily measure? A. Pain intensity based on a numeric rating B. Pain through facial expressions and physiological indicators C. Pain using visual analog scale images D. Pain by evaluating the patient's verbal descriptions B. Pain through facial expressions and physiological indicators A nurse is assessing an infant's pain using the CRIES Pain Scale and notes that the infant's heart rate is elevated, and they are crying intensely. How should these findings be interpreted according to the CRIES scale? A. The pain is likely minimal and not a concern B. The infant's pain level is moderate to severe C. The elevated heart rate and crying indicate no pain D. The findings suggest that the infant is comfortable B. The infant's pain level is moderate to severe A nurse is using the CRIES Pain Scale to evaluate a preterm infant's pain. Which of the following is an indicator used on the CRIES scale? A. Vocalization B. Facial expression C. Activity level D. Respiratory rate B. Facial expression A nurse is documenting the results of a CRIES Pain Scale assessment for an infant who scored 10 out of 10. What does this score indicate? A. No pain is present B. Mild pain C. Moderate pain D. Severe pain D. Severe pain A nurse is caring for four patients. Which patient should the nurse prioritize for immediate assessment? A. A patient with a blood pressure of 140/90 mmHg and a complaint of mild headache B. A postoperative patient with a temperature of 99.5°F and a heart rate of 85 bpm C. A patient with sudden onset of shortness of breath and oxygen saturation of 88% D. A patient with a dry cough and a respiratory rate of 18 breaths per minute C. A patient with sudden onset of shortness of breath and oxygen saturation of 88% A nurse is reviewing the following tasks for the shift: administering medications, performing wound care, and checking a patient's blood glucose level. Which task should the nurse prioritize? A. Administering medications B. Performing wound care C. Checking the patient's blood glucose level D. Completing all tasks in any order C. Checking the patient's blood glucose level A nurse is assigned to care for four patients. Which patient should be prioritized for monitoring first? A. A patient who is 1 day post-operative with a stable temperature B. A patient who is complaining of nausea and has a history of hypertension C. A patient who has a new-onset irregular heartbeat and is experiencing chest pain D. A patient who is receiving IV fluids and is reporting mild swelling at the insertion site C. A patient who has a new-onset irregular heartbeat and is experiencing chest pain A nurse is caring for a patient who has just been admitted to the unit and has several issues including a high fever, pain at an infusion site, and slight confusion. What should the nurse address first? A. The patient's high fever B. The pain at the infusion site C. The patient's slight confusion D. Documentation of all symptoms C. The patient's slight confusion A nurse is assessing pain in a non-verbal patient using the FLACC Pain Scale. What does the FLACC scale evaluate? A. Pain intensity through facial expressions and verbal descriptions B. Pain based on the patient's heart rate and blood pressure C. Pain using behavioral and physiological indicators, including facial expression, leg movement, activity, cry, and consolability D. Pain through the patient's ability to perform daily activities C. Pain using behavioral and physiological indicators, including facial expression, leg movement, activity, cry, and consolability A nurse is using the NIPS (Neonatal Infant Pain Scale) to assess a neonate's pain. Which of the following indicators does the NIPS include? A. Facial expression, crying, breathing pattern, leg movement, and posture B. Crying, facial expression, heart rate, blood pressure, and respiratory rate C. Facial expression, cry, sleep pattern, and physical activity D. Crying, facial expression, leg movement, and consolability A. Facial expression, crying, breathing pattern, leg movement, and posture A nurse is using the COMFORT Scale to evaluate pain in a pediatric patient who is non verbal. What aspects does the COMFORT Scale assess? A. Pain based on the child's ability to use a pain rating scale B. Pain through behavioral indicators including alertness, calmness, muscle tone, and physical activity C. Pain using facial expressions and physiological indicators like heart rate D. Pain by assessing the patient's verbal descriptions and pain history B. Pain through behavioral indicators including alertness, calmness, muscle tone, and physical activity A nurse is assessing pain in a patient with advanced dementia who cannot communicate verbally. Which non-verbal pain assessment tool would be most appropriate? A. Wong-Baker FACES Pain Rating Scale B. Numeric Pain Rating Scale C. PAINAD Scale (Pain Assessment in Advanced Dementia) D. Brief Pain Inventory C. PAINAD Scale (Pain Assessment in Advanced Dementia) A nurse is preparing to enter a patient's room who is on airborne precautions. Which type of PPE is required? A. Gown, gloves, and surgical mask B. Gown, gloves, and N95 respirator C. Gown, gloves, and face shield D. Surgical mask and gloves B. Gown, gloves, and N95 respirator A nurse is removing PPE after caring for a patient on contact precautions. What is the correct sequence for removing PPE? A. Remove gloves, then gown, then mask B. Remove gown, then gloves, then mask C. Remove gloves, then gown, then mask and face shield D. Remove mask, then gown, then gloves A. Remove gloves, then gown, then mask A nurse is providing education on PPE use to a patient's family. Which statement by the nurse indicates a correct understanding of when to use PPE? A. "PPE should be worn only if the patient has a known infectious disease." B. "PPE is used only during invasive procedures." C. "PPE is used based on the type of precautions needed, such as contact, droplet, or airborne." D. "PPE can be removed immediately after leaving the patient's room." C. "PPE is used based on the type of precautions needed, such as contact, droplet, or airborne." A nurse notices that a colleague is wearing an isolation gown incorrectly, with the gown's back exposed. What should the nurse do? A. Ignore it if the colleague is not directly caring for patients B. Gently remind the colleague to wear the gown with the back completely covered C. Report the issue to the infection control department immediately D. Advise the colleague to wash the gown and wear a new one B. Gently remind the colleague to wear the gown with the back completely covered A nurse is assessing a patient with a recent abdominal surgery and a patient with appendicitis. How does acute pain in these two conditions typically present? A. Both conditions show persistent pain with no relation to movement B. Acute pain from abdominal surgery often improves with movement, whereas appendicitis pain is generally worsened by movement C. Both conditions exhibit pain that is relieved with over-the-counter analgesics D. Pain in both conditions is usually described as dull and throbbing B. Acute pain from abdominal surgery often improves with movement, whereas appendicitis pain is generally worsened by movement A nurse is evaluating a patient with acute pain and a patient with a myocardial infarction (MI). What is a key difference in how these two types of pain are commonly described? A. Both are described as sharp and localized B. Acute pain from an injury is often described as dull and pressure-like, while MI pain is usually sharp and radiates to the arm or jaw C. MI pain is typically described as a squeezing or pressure sensation, whereas acute pain from an injury is often sharp and localized D. Both types of pain are usually accompanied by significant changes in blood pressure C. MI pain is typically described as a squeezing or pressure sensation, whereas acute pain from an injury is often sharp and localized A nurse is differentiating between acute pain due to a fracture and acute pain from a kidney stone. Which statement best describes the difference in the pain experienced? A. Fracture pain is usually intermittent, while kidney stone pain is constant B. Fracture pain is often described as sharp and localized, while kidney stone pain is typically described as colicky and may radiate from the flank to the groin C. Pain from a fracture is relieved by hydration, while kidney stone pain improves with rest D. Fracture pain is generally dull and achy, whereas kidney stone pain is sharp and localized B. Fracture pain is often described as sharp and localized, while kidney stone pain is typically described as colicky and may radiate from the flank to the groin A nurse is comparing the acute pain associated with an exacerbation of rheumatoid arthritis to that of an acute gastrointestinal bleed. What is a key difference in the pain characteristics? A. Rheumatoid arthritis pain is often relieved by anti-inflammatory medications, while gastrointestinal bleed pain is not typically responsive to these medications B. Pain from a gastrointestinal bleed is usually described as a dull ache, while rheumatoid arthritis pain is sharp and intermittent C. Rheumatoid arthritis pain is usually constant and improves with activity, while gastrointestinal bleed pain is intermittent and worsens with movement D. Gastrointestinal bleed pain is often relieved by antacids, while rheumatoid arthritis pain improves with physical therapy A. Rheumatoid arthritis pain is often relieved by anti-inflammatory medications, while gastrointestinal bleed pain is not typically responsive to these medications SBAR stands for? Situation, Background, Assessment, Recommendation History of present illness, past medical history are in what part of SBARR? Background "I think the problem is...," "the patient is unstable; we need to do something...," are part of what in SBARR? Assessment Identify yourself, the patient & code status. "The patient's vital signs are...," is what part of SBARR? Situation Gather specifics, assess if a follow up is necessary, make a recommendation....are what part of SBARR Recommendation What does ADPIE stand for in the nursing process? Assess, Diagnose, Plan, Implement, Evaluate Modes of transmission are... Direct and Indirect Direct modes of transmission include... Contact, Droplet, Airborne (air, kissing, touching) Indirect modes of transmission include... Vector (animate), Vehicle (inanimate)...Food, mosquitos, animals What are the 5 stages of infection? incubation, prodromal stage, acute, decline, convalescent Active immunity includes? naturally acquired (vaccines), antibodies, stimulated by an antigen, pathogen, or foreign substance. Passive immunity is? antibodies from mother to baby, blood transfusions serous clear, watery plasma sanguinous exudate bloody Serosanguineous Pale, pink, watery; mixture of clear and red fluid purulent containing pus Contact infection includes: MRS WEE... M:mrsa, mdro, vre R:respiratory, S:skin, W:wound, E:enteric (C.diff), E:eye Droplet Infection includes: SPIDERMAN ...S:sepsis, scarlett fever, streptococcal pharyngitis, P:pnemonia, pertussis, parvo, I:influenza, D:diptheria, E:epiglottitia R:rubella, M:meningitis, mumps A:adenovirus N:not specified Airborne infection include: MTV: Measles, Tuberculosis, Varicella What is neutropenic/reverse isolation used for? use for immune compromised patients. Private room, HEPPA filtration, PPE (no fresh flowers or fruit, cook food thoroughly). Contact precaution you must wear? Gloves & Gown Droplet Precaution must wear: minimum: gloves & mask Airborne Precaution must wear: N95, gloves DON (ON): Floor up: gown, mask, goggles, gloves DOFF (OFF): Alphabetical: gloves, goggles, gown, mask HAI's (Health-care Associated Infections CAUTI, wound infections, respiratory infections, bloodstream infections, MRSA. Sterile technique: aseptic technique, foley catheter, wound dressing, tracheal suctioning Clean technique asepsis, ng tube, enemas Normal heart rate 60-100 bpm Normal BP Systolic 90- 120 Diastolic 60- 80 Normal RR adult 12 to 20 breaths per minute normal oxygen saturation 94% tachycardia increased HR 100-180 bpm Bradycardia slow HR below 60 bpm Peripheral pulse sites temporal, carotid, brachial, radial, femoral, popliteal, posterior tibialis, dorsalis pedis Apical pulse location Mid clavicular line, 5th intercostal space Tachypnea increased respiratory rate bradypnea slow breathing Dyspnea difficult or labored breathing hyperventilation vs hypoventilation hyper=increased rate & depth (exercise, fear, diabetic ketoacidosis-kussmaul's respirations) hypo=decreased rate & depth (overdose of narcotics or anesthetics). Cheyne-Stokes respiration alternating periods of deep, rapid breathing, followed by periods of apnea (no breathing). oxygen saturation Measures hemoglobin's oxygen carrying capacity in a percentage (finger, toe, earlobe, forehead) blood pressure (BP) sitting position, legs uncrossed, arm at heart level ABCSIP Prioritization Airway, Breathing, Circulation, Safety, Inspection, Pain orthostatic hypotension low blood pressure that occurs upon standing up Is pain subjective or objective? subjective Pain Assessment OLD CART Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity Nonverbal signs of pain grimacing, crying, restlessness, irritability, furrowed brow, withdrawal nonpharmacological interventions guided imagery, music, relaxation, praying, distraction, change perception of pain Pharmacological interventions non-opioids NSAIDS (Tylenol, aspirin, ibuprofen) Pharmacological interventions Opioids morphine, Demerol, hydrocodone, Pharmacological interventions NSAIDS, opioids, topical, patient controlled analgesia (PCA) Patient-controlled analgesia (PCA) Self-administer opioids, Minimal risk of overdose, Offers a constant level of opioids within therapeutic range, Does not depend on nurse availability Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback A, C, E Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship B A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea C, D A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors A A nurse is caring for a client who is receiving morphine via patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary" B. "I'll be careful about pushing the button too much so I don't get an overdose" C. "I should tell the nurse if the pain doesn't stop while I am using this device" D. "I will ask my adult child to push the dose button while I am sleeping" C A nurse is caring for a client who is about to undergo coronary artery bypass graft surgery. The client asks the nurse, "I am going to die from this surgery?" The nurse replies, "You are to be just fine. Don't worry." The nurse's response is an example of: A. Validating B. False reassurance C. Clarifying D. Giving an opinion B A nurse has delegated vital signs to unlicensed assistive personnel (UAP) for a client who is in droplet precautions. For which of the following statements made by the UAP should the nurse provide further teaching? A. I will don my gown first prior to entering the client's room" B. I need to perform hand hygiene between steps, or if my hands become contaminated" C. "I need to don an N95 respirator mask prior to entering the client's room" D. "I will discard of my mask last when I have finished providing patient care" C The nurse is caring for four clients with the following abnormal vital signs. Which client should the nurse prioritize? A. Blood pressure of 157/98 B. Respiratory rate of 18 breathes per minute C. Heart rate of 103 beats per minute D. Oxygen saturation of 88% D The nurse is palpating bilateral radial arteries and notices an irregular rhythm. Which of the following actions should the nurse perform first? A. Notify the provider of the arrhythmia B. Assess the apical pulse for one full minute C. Palpate the carotid arteries D. Document the heart rate and rhythm B The nurse is caring for a client with orthostatic hypotension. Which of the following interventions should the nurse include in client teaching? (Select all that apply) A. Change positions slowly B. Dangle feet over the side of the bed before standing C. Discourage the use of a gait belt D. Utilizing wall railings when ambulating E. Wear non-skid socks when ambulating A,B,D,E The nurse is caring for a client who underwent a laparoscopic cholecystectomy. The client reports a pain level of 8 out of a scale of zero to ten. The nurse administers Morphine 2mg IV push as needed for pain. Upon reassessment, the nurse finds the client to have a respiratory rate of 6 breaths per minute. The nurse knows the client is experiencing a(n): A. Side effect B. Adverse effect C. Therapeutic effect D. Idiosyncratic effect B The nurse is caring for a client who recently suffered a cerebral vascular accident (CVA), leaving the patient with expressive aphasia. Which of the following scales would the nurse use to assess the client's pain? A. numerical B. Wong-Baker Faces C. FLACC D. Braden B One of the most common distinctions of pain is whether is it acute or chronic. Which examples describe chronic pain? (Select all that apply) A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysmd. A patient who has fibromyalgia requests pain m D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to a motor vehicle accident last year F. A patient experiencing pain from second-degree burns A,D,E A nurse is caring for a client with a blood pressure of 175/96. What other signs and symptoms may the nurse observe with this assessment finding? A. Unexplained pain and hyperactivity B. Headache, flushing of the face, and nosebleed C. Dizziness, mental confusion, and mottled extremities D. Restlessness and dusky or cyanotic skin that is cool to the touch B A client, who has been on bedrest for two days, is requesting to ambulate to the bathroom. The nurse has orders for "up ad lib." What action should the nurse take prior to ambulating the patient? A. Give the client non-skid socks and direct him to the bathroom B. Delegate ambulation to the unlicensed assistive personnel C. Obtain a set of orthostatic vital signs D. Provide a urinal for the client to void in C A nurse is caring for four clients and has decided to delegate the task of obtaining vital signs to the unlicensed assistive personnel (UAP). Which of the following clients would be most appropriate for the UAP to measure the client's vital signs? A. A client who recently started taking an antiarrhythmic medication B. A client with a history of transfusion reactions who is receiving a blood transfusion C. A client who has frequently been admitted to the unit with asthma attacks D. A client who is being admitted for elective surgery with a history of hypertension D A child is admitted to the pediatric unit with a suspected diagnosis of meningococcal meningitis. Which of the following nursing interventions should the nurse do first? A. Institute seizure precautions on the client B. Assess neurological status C. Place in droplet precautions D. Perform a head-to-toe assessment C Several clients are admitted to an adult medical unit. The nurse would initiate airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD test with an abnormal chest x-ray C. tentative diagnosis of viral pneumonia D. Advanced carcinoma of the lung B A nurse is preparing a sterile field. Which of the following guidelines should be followed? (Select all that apply) A. Never reach across a sterile field B. Objects below the waist are considered unsterile C. A dry area is microorganism-free D. A sterile object is considered sterile if touched by a clean glove E. One -inch margins along the edge of the field is considered unsterile20 A, B, E A nurse instructs a client in infection prevention. Which of the following statements made by the client indicates that the teaching was effective? A. "I should wash my hands before changing my wound dressing" B. The organisms on my skin will not infect my leg wound" C. "The dressing from my wound can be removed without wearing gloves" D. "The drainage from my wound can be rinsed down the kitchen sink" A A nurse in a long term care facility is performing client checks and observes a fire in a client's room. Which of the following should be the first action by the nurse? A- Activate the fire alarm B- Close all the doors and windows C- Evacuate the client from the room D- Extinguish the fire C- Evacuate the client from the room. Client safety is the priority, therefore evacuating the client from teh room is the first action the nurse should take. A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? A - provide support by holding the client's arm B - Lean the client toward the wall C- Lower the client to the floor D- Assume a narrow base of support C - lower the client to the floor This is an appropriate action. The nurse should gently lower the client to the floor. Which activity would be most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)? A - Assessing the patient for fall risk and complications of restraint use B - Evaluating the patient's ability to performs ADLs C - Assisting the patient with ADLs D- Teaching the patient how to use an assistive device for walking C - Assisting the patient with ADLs UAP can assist with the performance of ADLS A nurse is planning care for a client admitted with a positive culture for methicillin resistant Staphylococcus aureus (MRSA). Which prevention should be implemented to prevent spreading the infection to health care workers and other clients? A - Wearing a mask within 3 feet of the client B - Placing the client in a private room C - Wearing a N95 respirator mask D - Ensuring a negative air pressure room B - Placing the client in a private room Contact isolation A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A - If you wear gloves, you do not have to wash your hands B - Hand hygiene is crucial in preventing the spread of germs. C- Use an alcohol rub when your hands are visibly soiled D - If you do not have an infection, your hand won't infect others B- Handy hygiene is crucial in preventing the spread of germs Hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either the nurse or the client may have microorganisms on or in their body that do not harm them but may harm others. The nurse is documenting the client's nursing diagnosis as "Altered speech related to recent neurological disturbance as evidenced by inability to speak in complete sentences". Identify the defining characteristics below. A - "Altered speech" B - "As evidenced by" C - "Inability to speak in complete sentences" D - "recent neurological disturbance" C - "Inability to speak in complete sentences" The 3 step nursing diagnosis process is Problem r/t etiology aeb defining characteristics An unlicensed personnel (UAP) is obtaining a client's oral temperature. The client informs the UAP that he has just had some ice chips. Which of the following is an appropriate action by the UAP? A- Wait 20-30 minutes and return to take the oral temperature B - provide a sip of warm water, wait 5 minutes and take the temperature C- Document that a temperature was unable to be obtained D - Proceed to take the oral temperature A - Wait 20-30 minutes and return to take the oral temperature Healthcare workers need to wait 20-30 minutes and then take the oral temperature because the ice will artificially lower the clients' temperature. A nurse is caring for a client who is suspected of having measles. The nurse should assure the client is placed on which transmission based precaution? A-Droplet B - Airborne C- Contact D -Protective B - Airborne The nurse decides to interview the client using open-ended question techniques. Which of the following statements best reflects this type of questioning? A- Is your pain worse or better than it was an hour ago? B - Do you believe that your nausea is from the pain medication? C- Tell me what you think is causing your current sadness? D - Can you tell me what you have done to alleviate the side effects from your medication. C - Tell me what you think is causing your current sadness Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate every 6 hours daily in hallway before discharge"? a. Goal met; patient stated he ambulated. b. Goal met; patient ambulated three times in hallway. c. Goal partially met; patient ambulated every 6 hours daily. d. Goal met; patient ambulated every 6 hours daily D - Goal met; patient ambulated every 6 hours daily This is an observed statement by the nurse A nurse is preparing to admit a client who is diagnosed with Hepatitis C (HCV). Which of the following precautions should the nurse anticipate implementing? A - Droplet B - Contact C- Airborne D - Standard D - Standard Hepatitis C is a blood borne pathogen. A mask, eye protection, face shield and gown should be word if there is a risk for splashes or sprays of blood of body fluids. The client states he is "feeling hot". The nurse takes the client's temperature and finds it to be 97.6 degrees F. In addition, the pulse rate is 88 bveats per minute and his blood pressure is 168/80 mm/Hg. Client has a blood pressure pill scheduled for this morning. Which of the following is an example of subjective data? A - Pulse rate B - Blood pressure 168/80 mm Hg. C - The statement regarding "feeling hot". D -Client is scheduled to receive a blood pressure pill this morning. C - The statement regarding "feeling hot". A nurse is admitting a client who has pulmonary tuberculosis and a productive cough. Besides standard precautions, which type of precautions should the nurse add to the client's plan of care? A - Contact B - Droplet C -Protective D -Airborne D -Airborne Tuberculosis is a respiratory infection that spreads through the air, so clients who have it require airborne isolation. The client needs a private room with negative airflow and at least six to 12 air exchanges/hourly. A nurse is caring for a client who is requesting pain medication. Which of the following actions should the nurse perform first? A-Reposition the client. B-Administer the medication. C-Determine the location of the pain. D-Review the effects of the pain medication. C-Determine the location of the pain. Using the nursing process, assessment of the location of the pain is priority action by the nurse. The unlicensed assistive personnel reports vital signs for a patient to the nurse: temperature 99.2 degrees F oral, pulse 88 bpm, and respirations 18 bpm, blood pressure148/94, oxygen saturation 96%, and pain of 0. Which vital sign should the nurse be most concerned of? A. Temperature B. Pulse C. Blood pressure D. Respirations C. Blood pressure within normal limit blood pressure is 100/60-140/90. The nurse is caring for four (4) clients. The assistive personnel (AP) input the following vital signs into the electronic health record (EHR). Which client should the nurse see first? A. Client 1: T = 97.8 P = 66 R = 14 BP = 122/72 Pulse Ox = 95% B. Client 2: T = 98.2 P = 70 R = 10 BP = 128/74 Pulse Ox = 95% C. Client 3: T = 98.6 P = 80 R = 18 BP = 106/66 Pulse Ox = 97% D. Client 4: T = 98.1 P = 84 R = 18 BP = 132/66 Pulse Ox = 100% B. Client 2: T = 98.2 P = 70 R = 10 BP = 128/74 Pulse Ox = 95% R = 10 WDL =12-20 The nurse is performing an initial assessment of a patient. Vital signs for the patient indicate hypotension (low blood pressure) and tachycardia (fast heart rate). Which data pair would support this evaluation? A. Pulse 88, blood pressure 140/88. B. Pulse 96, blood pressure 120/76. C. Pulse 100, blood pressure 118/80. D. Pulse 104, blood pressure 98/66. D. Pulse 104, blood pressure 98/66. Pulse is 100 bpm, Blood pressure systolic 100 is hypotension. A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require the nurse to wear gloves? (Select all that apply). A. Emptying urine from a urinal. B. Providing oral care. C. Delivering a food tray to a client. D. Washing the client's perineal area. A. Emptying urine from a urinal. B. Providing oral care. D. Washing the client's perineal area. A nurse is planning to delegate tasks to an unlicensed assistive personnel (UAP). Which of the following tasks should the nurse plan to perform? A. Transfer of a client from bed to chair. B. Putting anti-embolic stockings on the client's legs. C. Assessing the client's skin for redness. D. Assisting a client to the bathroom. C - Assessing the client's skin for redness. Assessment techniques specialized knowledge of the nurse and cannot be delegated to an AP. A nurse is changing the client's arm dressing and accidentally drops the dressing on the bed. The client has a large incision in his arm. The nurse should? A. Add alcohol to the dressing and insert it into the incision to assure sterility. B. Throw the dressing away and prepare a new dressing. C. Pick up the dressing and gently place it into the incision site. D. Since the dressing is on the client's bed sheets there is no issue. B. Throw the dressing away and prepare a new dressing. Assures sterility. After measuring the client's vital signs using an electronic vital sign machine, the nurse obtains the following results: T=98.2, P=62, BP= 170/62, Pulse O = 96%. The nurse should? A. Report findings to the primary healthcare provider immediately. B. Retake the client's temperature using a thermometer versus an electronic thermometer. C. Retake the blood pressure manually. D. Document the findings because they are within normal limits. C. Retake the blood pressure manually. This demonstrates the nursing using critical thinking skills in making assessment. It could be that the electronic vital sign machine is not calibrated correctly or not working correctly. A nurse is preparing to collect health history data during a client admission. Which of the following questions by the nurse best promotes this discussion? A. "Tell me what brought you to the hospital." B. "Would you tell me about all of your medical issues?" C. "Do you want to talk about your health concerns?" D. "Would it help to discuss your feelings about this hospitalization?" A. "Tell me what brought you to the hospital. This response is focused, open ended statement. Open ended questions allow a client to tell his or her story in detail. It invites the client to communicate. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem oriented database the nurse should first question the client about? A. Tell me when did it start and how long have you been experiencing the breathing problem. B. His personal smoking history. C. Changes in other body systems that the client perceives as problematic. D. Assess for respiratory risk exposure, question client on current occupation and living environment. A - Tell me when did it start and how long have you been experience the breathing problem. The nurse should first ask the client about the onset, severity and duration of the problem - the client's current health problem becomes the priority assessment. Priority ABC. The nurse is reviewing the following vital signs. The nurse recognizes that the following vital signs are within the expected range for an adult client. Select all that apply. A. Temperature 98.4 degrees F B. Blood pressure 110/70mm/hg C. Pulse 140 bpm D. 90% Pulse Ox E. Pulse 50 bpm F. Respiration 18 bpm A. Temperature 98.4 degrees F B. Blood pressure 110/70mm/hg F. Respiration 18 bpm The nurse is planning to perform oral care to a semi-comatose patient. The nurse should place the patient in which of the following position to avoid any aspiration of water used for cleansing the clients oral cavity: A. Transfer client to a recliner and have head turned toward the nurse B. Side-lying with the head turned toward the nurse, consider having oral suctioning available. C. Head of bed raised to a 90 degree angle, client in a sitting position with the head turned toward the nurse D. Lying flat with the client's neck positioned slightly forward toward the nurse B. Side-lying with the head turned toward the nurse, consider having oral suctioning available. A, C, D increases risk for aspiration and causing an airway obstruction The Nurse Manager observes a new staff nurse perform the following actions for a patient with isolation precautions. Which of the following actions should the Nurse Manager address and correct with the new nurse? A. Keeping a thermometer, stethoscope, and blood pressure cuff in the patient's room. B. Documenting the isolation precautions required in the patient's medical record and nursing care plan. C. Using a particulate N95 mask for the patient who has been placed on airborne isolation. D. Coming out of the patient's room in the personal protective equipment (PPE) to get another dressing and other supplies. D. Coming out of the patient's room in the personal protective equipment (PPE) to get another dressing and other supplies. A, B, C are all correct interventions and activities for clients who are on isolation precautions. During a physical examination, a nurse should assess the temperature of the patient's skin using the: A. Dorsal aspect of the hand. B. Pads of the fingers. C. Palm surface of the hand. D. Using the fingertips. A - Dorsal aspect of the hand Using the dorsal aspect of the hand allows the nurse to assess temperature. A patient with diarrhea has been diagnosed with Clostridium difficile. Along with standard precautions, which kind of transmission-based precautions will be used when the nurse is caring for this patient? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Protective isolation precautions B. Contact precautions The nurse is setting patient goals. What phase of the nursing process is the nurse using? A. Assessment B. Nurse Diagnosis C. Planning D. Implementation E. Evaluation C - Planning Priority setting is accomplished during the planning phase. The nurse is bathing the client. What phase of the nursing process is the nursing utilizing? A. Assessment B. Nurse Diagnosis C. Planning D. Implementation E. Evaluation D - Implementation The nurse is measuring client goal achievement. What phase of the nursing process is the nurse utilizing? A. Assessment B. Nurse Diagnosis C. Planning D. Implementation E. Evaluation E - Evaluation Nurse utilizes, goal met, partially met, not met The nurse is identifying the clients assets/liabilities, strengths/weakness and ability to perform a variety of activities of daily living. What phase of the nursing process is the nurse utilizing? A. Assessment B. Nurse Diagnosis C. Planning D. Implementation E. Evaluation A - Assessment The nurse is collecting data = assessment The nurse has clustered data collected. The nurse will analyze the data to? A. Collect additional assessment data. B. Identify a Nursing Diagnosis. C. Develop a plan of care and goal. D. Implement the nursing care plan. E. Decide if the goal was met. B - Identify a Nursing Diagnosis Clustered data is utilized to develop a Nursing Diagnosis After taking vital signs, the nurse writes down finding as T=98.6, P=66, R=18, BP=124/82, Sp02=97%. Which number represents the systolic blood pressure? A. 98.6 B. 66 C. 18 D. 124 E. 82 F. 97% D. 124 The nurse is taking the client's pulse oxygen on a client lying flat in bed. The pulse oximetry monitor indicates a SpO2 of 90%. What actions the should the nurse take? Select all that apply. A. Tell the patient to breathe, "smell the roses/blow out the candles". B. Raise the head of the bed so that the patient is sitting upright. C. Administer oxygen 2 liters via a nasal cannula immediately. D. Keep the pulse oximeter on the client's finger to assess oxygen level. A.Tell the patient to breathe, "smell the roses/blow out the candles". B. Raise the head of the bed so that the patient is sitting upright. D. Keep the pulse oximeter on the client's finger to assess oxygen level. The nurse describes the radial pulse as "weak and irregular" after taking morning vital signs. The most appropriate follow-up nursing action is to? A. Notify the doctor B. Check the apical pulse C. Document the pulse D. Check the previous pulse B. Check the apical pulse The nurse is auscultating an apical pulse on a client. In counting the apical pulse, the nurse counts? A. Each lub-dub as two beats for 1 minute. B. Each lub-dub for 10 seconds and then multiplies by 6 C. Each lub-dub as one beat for 1 minute. D. Each lub-dub for 20 seconds then multiply by 3. C. Each lub-dub as one beat for 1 minute. Lub-dub = 1 beat. The apical is to be counted for 1 solid minute. The client fell at home and injured her left lower leg extremity. The nurse should? A. Count the left brachial pulse for 30 seconds. B. Palpate the left femoral pulse. C. Palpate the left dorsalis-pedis pulse. D. Palpate the