NR304 CJE
COMPREHENSIVE
STUDY GUIDE
SECTION 1: VITAL SIGNS & BASIC ASSESSMENT
QUESTION 1
What action ensures the most accurate blood pressure reading for a client who just arrived?
ANSWER
Take the blood pressure several minutes after the client has entered the room.
RATIONALE / EXPLANATION
Waiting allows the client to rest and reduces the effects of physical activity or anxiety on blood
pressure readings. Immediate readings may be falsely elevated.
QUESTION 2
What is the anticipated result of using a BP cuff that is too small on a 294 lb client?
ANSWER
False high reading.
RATIONALE / EXPLANATION
A cuff that is too small will not adequately compress the artery, resulting in falsely elevated blood
pressure readings. Use appropriate cuff size for accurate measurement.
QUESTION 3
What is the most concerning vital sign for a patient with BP 89/65 and HR 90?
ANSWER
Blood Pressure (Hypotension).
RATIONALE / EXPLANATION
BP 89/65 indicates hypotension which can lead to inadequate organ perfusion. While HR 90
Page 1 of 40
,shows compensation, the low BP is the primary concern requiring intervention.
QUESTION 4
What condition is indicated by a client's vitals changing from BP 160/99 to BP 104/46?
ANSWER
Tachycardia related to hypotension.
RATIONALE / EXPLANATION
This significant drop in blood pressure indicates possible hypovolemia or shock. The body
compensates with tachycardia to maintain cardiac output.
QUESTION 5
What is the most appropriate response for a nurse after obtaining BP readings indicating
orthostatic hypotension?
ANSWER
Please call for assistance when getting out of bed.
RATIONALE / EXPLANATION
Orthostatic hypotension increases fall risk. The client should call for help before ambulating to
prevent falls from dizziness or syncope.
QUESTION 6
What is the Glasgow Coma Score for a client who is alert and oriented?
ANSWER
15
RATIONALE / EXPLANATION
GCS of 15 (highest score): Eyes open spontaneously (4) + Oriented verbal response (5) + Obeys
commands (6) = 15. This indicates normal neurological function.
Page 2 of 40
, SECTION 2: CARDIAC ASSESSMENT
QUESTION 7
What indicates understanding when listening to the apical heart rate before administering a
cardiac drug?
ANSWER
Places the stethoscope at the 5th intercostal space, left side at the mid-
clavicular line.
RATIONALE / EXPLANATION
This is the correct anatomical location for the apex of the heart (Point of Maximum Impulse/PMI)
where the apical pulse is best heard.
QUESTION 8
What priority action should the nurse take if a 79-year-old client's apical pulse has an
occasional missed beat?
ANSWER
Auscultate the apical pulse while simultaneously palpating the radial pulse.
RATIONALE / EXPLANATION
This technique detects pulse deficit (difference between apical and radial rates), which may
indicate atrial fibrillation or other arrhythmias requiring further evaluation.
QUESTION 9
What assessment technique will the nurse use to detect a 'bruit'?
ANSWER
Auscultation
RATIONALE / EXPLANATION
A bruit is an abnormal whooshing sound caused by turbulent blood flow through a narrowed or
diseased artery. It can only be detected by listening with a stethoscope.
Page 3 of 40
, SECTION 3: RESPIRATORY ASSESSMENT
QUESTION 10
What priority action should the nurse take for a client with coughing, wheezing, and cyanotic
lips?
ANSWER
Assess the airway
RATIONALE / EXPLANATION
Airway is always the first priority (ABC). Cyanotic lips indicate hypoxia, and wheezing suggests
airway compromise. Ensure the airway is patent before other interventions.
QUESTION 11
What finding supports Cheyne-Stokes respirations in a hospice client?
ANSWER
Rhythmic respirations with periods of apnea.
RATIONALE / EXPLANATION
Cheyne-Stokes breathing is characterized by a crescendo-decrescendo pattern of breathing with
periods of apnea. Common in end-of-life and indicates brainstem dysfunction.
QUESTION 12
What finding indicates a pneumothorax?
ANSWER
Rapid breathing/HR with asymmetrical lateral chest movement.
RATIONALE / EXPLANATION
Asymmetrical chest movement (one side not expanding) with tachypnea and tachycardia are
classic signs of pneumothorax. The affected side will have decreased or absent breath sounds.
QUESTION 13
Page 4 of 40
COMPREHENSIVE
STUDY GUIDE
SECTION 1: VITAL SIGNS & BASIC ASSESSMENT
QUESTION 1
What action ensures the most accurate blood pressure reading for a client who just arrived?
ANSWER
Take the blood pressure several minutes after the client has entered the room.
RATIONALE / EXPLANATION
Waiting allows the client to rest and reduces the effects of physical activity or anxiety on blood
pressure readings. Immediate readings may be falsely elevated.
QUESTION 2
What is the anticipated result of using a BP cuff that is too small on a 294 lb client?
ANSWER
False high reading.
RATIONALE / EXPLANATION
A cuff that is too small will not adequately compress the artery, resulting in falsely elevated blood
pressure readings. Use appropriate cuff size for accurate measurement.
QUESTION 3
What is the most concerning vital sign for a patient with BP 89/65 and HR 90?
ANSWER
Blood Pressure (Hypotension).
RATIONALE / EXPLANATION
BP 89/65 indicates hypotension which can lead to inadequate organ perfusion. While HR 90
Page 1 of 40
,shows compensation, the low BP is the primary concern requiring intervention.
QUESTION 4
What condition is indicated by a client's vitals changing from BP 160/99 to BP 104/46?
ANSWER
Tachycardia related to hypotension.
RATIONALE / EXPLANATION
This significant drop in blood pressure indicates possible hypovolemia or shock. The body
compensates with tachycardia to maintain cardiac output.
QUESTION 5
What is the most appropriate response for a nurse after obtaining BP readings indicating
orthostatic hypotension?
ANSWER
Please call for assistance when getting out of bed.
RATIONALE / EXPLANATION
Orthostatic hypotension increases fall risk. The client should call for help before ambulating to
prevent falls from dizziness or syncope.
QUESTION 6
What is the Glasgow Coma Score for a client who is alert and oriented?
ANSWER
15
RATIONALE / EXPLANATION
GCS of 15 (highest score): Eyes open spontaneously (4) + Oriented verbal response (5) + Obeys
commands (6) = 15. This indicates normal neurological function.
Page 2 of 40
, SECTION 2: CARDIAC ASSESSMENT
QUESTION 7
What indicates understanding when listening to the apical heart rate before administering a
cardiac drug?
ANSWER
Places the stethoscope at the 5th intercostal space, left side at the mid-
clavicular line.
RATIONALE / EXPLANATION
This is the correct anatomical location for the apex of the heart (Point of Maximum Impulse/PMI)
where the apical pulse is best heard.
QUESTION 8
What priority action should the nurse take if a 79-year-old client's apical pulse has an
occasional missed beat?
ANSWER
Auscultate the apical pulse while simultaneously palpating the radial pulse.
RATIONALE / EXPLANATION
This technique detects pulse deficit (difference between apical and radial rates), which may
indicate atrial fibrillation or other arrhythmias requiring further evaluation.
QUESTION 9
What assessment technique will the nurse use to detect a 'bruit'?
ANSWER
Auscultation
RATIONALE / EXPLANATION
A bruit is an abnormal whooshing sound caused by turbulent blood flow through a narrowed or
diseased artery. It can only be detected by listening with a stethoscope.
Page 3 of 40
, SECTION 3: RESPIRATORY ASSESSMENT
QUESTION 10
What priority action should the nurse take for a client with coughing, wheezing, and cyanotic
lips?
ANSWER
Assess the airway
RATIONALE / EXPLANATION
Airway is always the first priority (ABC). Cyanotic lips indicate hypoxia, and wheezing suggests
airway compromise. Ensure the airway is patent before other interventions.
QUESTION 11
What finding supports Cheyne-Stokes respirations in a hospice client?
ANSWER
Rhythmic respirations with periods of apnea.
RATIONALE / EXPLANATION
Cheyne-Stokes breathing is characterized by a crescendo-decrescendo pattern of breathing with
periods of apnea. Common in end-of-life and indicates brainstem dysfunction.
QUESTION 12
What finding indicates a pneumothorax?
ANSWER
Rapid breathing/HR with asymmetrical lateral chest movement.
RATIONALE / EXPLANATION
Asymmetrical chest movement (one side not expanding) with tachypnea and tachycardia are
classic signs of pneumothorax. The affected side will have decreased or absent breath sounds.
QUESTION 13
Page 4 of 40
