Question 1. What is the primary purpose of
initially assessing an apical pulse?
Your Answer: B What is the major health problem resulting from a
pulse deficit?
Establishment of a baseline as part of the
patient’s vital signs Your Answer: C
Question 2. What instruction should the nurse give Decreased cardiac output
nursing assistive personnel (NAP)
regarding the appropriate technique when
measuring the adultpatient’s apical
pulse? Question 2.
Your Answer: D What should the nurse do when a
pulse deficit is suspected?
Place your stethoscope at the fifth
intercostal space over the left Your Answer: D
midclavicular line.
Ask another health care provider
to count the radial pulse while
Question 3. the nurse counts the apical pulse.
Which action would take priority if a
patient’s apical pulse has an irregular
rhythm?
Your Answer: A Question 3.
Reassess the pulse for 1 full minute. Which action should the nurse
perform after identifying a pulse
deficit?
Question 4.
Your Answer: B
Which statement demonstrates an
understanding of the importance of
communicating changes in the patient’s
Assess the patient for signs of
apical pulse rate? decreased cardiac output.
Your Answer: D
“The apical pulse increased from 78to Question 4.
110, but the patient had just returned from
the bathroom.”
Which of the following is
an early manifestation of
decreased cardiac output?
Question 5. Your Answer:
The nurse can best determine the effect
of crying on a patient’s apicalpulse by AFatigue
doing what?
Your Answer: C
Comparing the patient’s post-crying
apical pulse rate with her baseline or
previous rate.
, Question 5.
You have the following information:
Oral temperature–36.8°C. Radial Pulse–112 weak, thread, Apical pulse–117 regular, Respirations–24 regular
Blood Pressure–104/56 right arm –102/50 left arm
What is the pulse deficit?
Your Answer: B- 5
Question 1.
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of hiscolon. What is
the most reliable sign that the patient has significant postoperative pain?
Your Answer: A
The patient rates his pain a 7 on a scale of 0 to 10.
Question 2.
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of apatient’s
pain?
Your Answer: A
“Let me know at least 30 minutes before you transport her so I can administer her analgesics.”
Question 3.
Which observation indicates that a patient’s analgesic has been effective in managing pain that sherated a 6 out of
10 on a pain rating scale before the intervention?
Your Answer: B
The patient rates her current pain as 3 out of 10 on the pain rating scale.
Question 4.
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine.Which activity is
most likely to be a palliative factor for this patient?
Your Answer: C
Performing neck, back, and shoulder exercises prescribed by a physical therapist
Question 5.
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as
diaphoresis, tachycardia, and hypertension. The patient does, however, seem moodyand a bit uncooperative.
What conclusion does the nurse draw?
Your Answer: C
The absence of physiological signs and symptoms is associated with chronic pain.
initially assessing an apical pulse?
Your Answer: B What is the major health problem resulting from a
pulse deficit?
Establishment of a baseline as part of the
patient’s vital signs Your Answer: C
Question 2. What instruction should the nurse give Decreased cardiac output
nursing assistive personnel (NAP)
regarding the appropriate technique when
measuring the adultpatient’s apical
pulse? Question 2.
Your Answer: D What should the nurse do when a
pulse deficit is suspected?
Place your stethoscope at the fifth
intercostal space over the left Your Answer: D
midclavicular line.
Ask another health care provider
to count the radial pulse while
Question 3. the nurse counts the apical pulse.
Which action would take priority if a
patient’s apical pulse has an irregular
rhythm?
Your Answer: A Question 3.
Reassess the pulse for 1 full minute. Which action should the nurse
perform after identifying a pulse
deficit?
Question 4.
Your Answer: B
Which statement demonstrates an
understanding of the importance of
communicating changes in the patient’s
Assess the patient for signs of
apical pulse rate? decreased cardiac output.
Your Answer: D
“The apical pulse increased from 78to Question 4.
110, but the patient had just returned from
the bathroom.”
Which of the following is
an early manifestation of
decreased cardiac output?
Question 5. Your Answer:
The nurse can best determine the effect
of crying on a patient’s apicalpulse by AFatigue
doing what?
Your Answer: C
Comparing the patient’s post-crying
apical pulse rate with her baseline or
previous rate.
, Question 5.
You have the following information:
Oral temperature–36.8°C. Radial Pulse–112 weak, thread, Apical pulse–117 regular, Respirations–24 regular
Blood Pressure–104/56 right arm –102/50 left arm
What is the pulse deficit?
Your Answer: B- 5
Question 1.
A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of hiscolon. What is
the most reliable sign that the patient has significant postoperative pain?
Your Answer: A
The patient rates his pain a 7 on a scale of 0 to 10.
Question 2.
What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of apatient’s
pain?
Your Answer: A
“Let me know at least 30 minutes before you transport her so I can administer her analgesics.”
Question 3.
Which observation indicates that a patient’s analgesic has been effective in managing pain that sherated a 6 out of
10 on a pain rating scale before the intervention?
Your Answer: B
The patient rates her current pain as 3 out of 10 on the pain rating scale.
Question 4.
A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine.Which activity is
most likely to be a palliative factor for this patient?
Your Answer: C
Performing neck, back, and shoulder exercises prescribed by a physical therapist
Question 5.
The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as
diaphoresis, tachycardia, and hypertension. The patient does, however, seem moodyand a bit uncooperative.
What conclusion does the nurse draw?
Your Answer: C
The absence of physiological signs and symptoms is associated with chronic pain.
