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.
Give this one a try later!
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.
,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.
Give this one a try later!
A - Dorsal aspect of the hand
Using the dorsal aspect of the hand allows the nurse to assess temperature.
The nurse is assessing vital signs. The nurse would be concerned with which vital
sign?
A. T=96.9F
B. P=88
C. R=18
D. BP=132/70
E. Pulse Ox = 91%
Give this one a try later!
E. Pulse Ox = 91%
Pulse ox wnl = 95% or higher
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.
Give this one a try later!
B. Throw the dressing away and prepare a new dressing.
Assures sterility.
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.
Give this one a try later!
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.
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.
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.
Give this one a try later!
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.
,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.
Give this one a try later!
A - Dorsal aspect of the hand
Using the dorsal aspect of the hand allows the nurse to assess temperature.
The nurse is assessing vital signs. The nurse would be concerned with which vital
sign?
A. T=96.9F
B. P=88
C. R=18
D. BP=132/70
E. Pulse Ox = 91%
Give this one a try later!
E. Pulse Ox = 91%
Pulse ox wnl = 95% or higher
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.
Give this one a try later!
B. Throw the dressing away and prepare a new dressing.
Assures sterility.
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.
Give this one a try later!
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.
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.
