Fundamentals of Nursing Ch. 25 Exam Practice
Questions with Correct Solutions & Explanations
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can
anticipate that the digoxin will: - Answer decrease the apical pulse.
Clients demonstrating apnea have what? - Answer a temporary cessation of breathing
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect
core body temperature of the client? - Answer rectum
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What
should the nurse do next? - Answer Use the Doppler ultrasound device.
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing
intervention? - Answer Provide privacy for the client.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes
that the phase I sound disappears for 2 seconds. What should the nurse document on the progress
record? - Answer There is an auscultatory gap.
During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110 mmHg.
Why is this finding particularly significant? - Answer It deviates from normal and is significant.
Which client should not have a temperature assessed rectally? - Answer Client with diarrhea
Which are considered vital signs? Select all that apply. - Answer temperature
respiratory rate
blood pressure
pulse
, During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5
inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. - Answer True
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac
medication. The nurse can anticipate that the digoxin will: - Answer decrease the apical pulse.
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The
client asks why it is so important to do this. What is the nurse's best response? - Answer "Monitoring
your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and
stroke."
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse
perform after placing the diaphragm over the apex of the heart? - Answer Listen for heart sounds.
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the
nurse provide to the client? - Answer "Dizziness when you change position can occur when fluid volume
in the body is decreased."
A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate
to decrease the risk of falls? Select all that apply. - Answer encourage slow movement from the bed to
the chair
encourage the client to use the call light prior to getting out of bed
encourage oral fluid intake
encourage the use of the call light for help to the bathroom
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which
observation can be made by the nurse and athletes by measuring the blood pressure? - Answer the
ability of the arteries to stretch
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a
thready pulse. Which of the following is a description of a thready pulse? - Answer Pulse is felt with
difficulty and disappears with slight pressure.
Questions with Correct Solutions & Explanations
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can
anticipate that the digoxin will: - Answer decrease the apical pulse.
Clients demonstrating apnea have what? - Answer a temporary cessation of breathing
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect
core body temperature of the client? - Answer rectum
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What
should the nurse do next? - Answer Use the Doppler ultrasound device.
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing
intervention? - Answer Provide privacy for the client.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes
that the phase I sound disappears for 2 seconds. What should the nurse document on the progress
record? - Answer There is an auscultatory gap.
During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110 mmHg.
Why is this finding particularly significant? - Answer It deviates from normal and is significant.
Which client should not have a temperature assessed rectally? - Answer Client with diarrhea
Which are considered vital signs? Select all that apply. - Answer temperature
respiratory rate
blood pressure
pulse
, During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5
inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant. - Answer True
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac
medication. The nurse can anticipate that the digoxin will: - Answer decrease the apical pulse.
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The
client asks why it is so important to do this. What is the nurse's best response? - Answer "Monitoring
your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and
stroke."
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse
perform after placing the diaphragm over the apex of the heart? - Answer Listen for heart sounds.
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the
nurse provide to the client? - Answer "Dizziness when you change position can occur when fluid volume
in the body is decreased."
A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate
to decrease the risk of falls? Select all that apply. - Answer encourage slow movement from the bed to
the chair
encourage the client to use the call light prior to getting out of bed
encourage oral fluid intake
encourage the use of the call light for help to the bathroom
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which
observation can be made by the nurse and athletes by measuring the blood pressure? - Answer the
ability of the arteries to stretch
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a
thready pulse. Which of the following is a description of a thready pulse? - Answer Pulse is felt with
difficulty and disappears with slight pressure.
