Fundamentals of Nursing NCLEX
Practice Questions Quiz #4 | 75
Questions
FNDNRS-04-001
All of the following can cause tachycardia except:
A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation
Correct Answer: D. Parasympathetic nervous system stimulation
Parasympathetic nervous system stimulation of the heart decreases the heart rate
as well as the force of contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and sympathetic stimulation all
increase the heart rate. The parasympathetic nervous system (PNS) releases the
hormone acetylcholine to slow the heart rate. Such factors as stress, caffeine, and
excitement may temporarily accelerate your heart rate, while meditating or taking
slow, deep breaths may help to slow your heart rate.
Option A: Tachypnea and tachycardia develop, and the patient becomes
dehydrated because of sweating and vapor losses from the increased
respiratory rate. Many manifestations of fever are related to the increased
metabolic rate, increased need for oxygen, and use of body proteins as an
energy source.
Option B: Often, ventricular tachycardia will occur during the recovery
period post exercise due to increased levels of adrenaline. In a study
conducted in 1991, it was found that 70% of patients tested experienced
idiopathic ventricular tachycardia as a result of exercise. Exercising for any
duration will increase your heart rate and will remain elevated for as long
as the exercise is continued. At the beginning of exercise, your body
removes the parasympathetic stimulation, which enables the heart rate to
, gradually increase. As you exercise more strenuously, the sympathetic
system “kicks in” to accelerate your heart rate even more.
Option C: Heart rate is controlled by the two branches of the autonomic
(involuntary) nervous system. The sympathetic nervous system (SNS) and
the parasympathetic nervous system (PNS). The sympathetic nervous
system (SNS) releases the hormones (catecholamines – epinephrine and
norepinephrine) to accelerate the heart rate.
FNDNRS-04-002
Palpating the midclavicular line is the correct technique for assessing:
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
Correct Answer: D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Assessing whether
the rhythm of the pulse is regular or irregular is essential. The pulse could be
regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along
with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the
pulse rate becomes faster during inspiration and slows down during expiration.
Irregularly irregular pattern is more commonly indicative of processes like atrial
flutter or atrial fibrillation.
Option A: Baseline vital signs include pulse rate, temperature, respiratory
rate, and blood pressure. Vital signs are an objective measurement for the
essential physiological functions of a living organism. They have the name
“vital” as their measurement and assessment is the critical first step for any
clinic evaluation. The first set of clinical examinations is an evaluation of the
vital signs of the patient.
Option B: Blood pressure is typically assessed at the antecubital fossa. The
arm should be supported at the heart level. Unsupported arm leads to 10
mmHg to the pressure readings. The patient’s blood pressure should get
, checked in each arm, and in younger patients, it should be tested in an
upper and lower extremity to rule out the coarctation of the aorta.
Option C: Respiratory rate is assessed best by observing chest movement
with each inspiration and expiration. The respiratory rate is the number of
breaths per minute. The normal breathing rate is about 12 to 20 beats per
minute in an average adult. In the pediatric age group, it is defined by the
particular age group. Parameters important here again include its rate,
depth of breathing, and its pattern rate of breathing is a crucial parameter.
FNDNRS-04-003
The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral
Correct Answer: C. Pedal
Because the pedal pulse cannot be detected in 10% to 20% of the population, its
absence is not necessarily a significant finding. However, the presence or absence
of the pedal pulse should be documented upon admission so that changes can
be identified during the hospital stay. Absent peripheral pulses may be indicative
of peripheral vascular disease (PVD). PVD may be caused by atherosclerosis,
which can be complicated by an occluding thrombus or embolus. This may be
life-threatening and may cause the loss of a limb.
Option A: Apical pulse rate is indicated during some assessments, such as
when conducting a cardiovascular assessment and when a client is taking
certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration. It is also a best
practice to assess apical pulse in infants and children up to five years of
age because radial pulses are difficult to palpate and count in this
population.
, Option B: Examiners frequently evaluate the radial artery during a routine
examination of adults, due to the unobtrusive position required to palpate
it and it’s easy accessibility in various types of clothing. Like other distal
peripheral pulses (such as those in the feet) it also may be quicker to show
signs of pathology. Palpation is at the anterior wrist just proximal to the
base of the thumb.
Option D: The femoral pulse may be the most sensitive in assessing for
septic shock and is routinely checked during resuscitation. It is palpated
distally to the inguinal ligament at a point less than halfway from the pubis
to the anterior superior iliac spine.
FNDNRS-04-004
Which of the following patients is at greatest risk for developing pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids and aspirin.
B. An 88-year old incontinent patient with gastric cancer who is confined to
his bed at home.
C. An apathetic 63-year old COPD patient receiving nasal oxygen via
cannula.
D. A confused 78-year old patient with congestive heart failure (CHF) who
requires assistance to get out of bed.
Correct Answer: B. An 88-year old incontinent patient with gastric cancer
who is confined to his bed at home.
Pressure ulcers are most likely to develop in patients with impaired mental status,
mobility, activity level, nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition
(from gastric cancer) and is confined to bed is at greater risk. Pressure injuries are
defined as localized damage to the skin as well as underlying soft tissue, usually
occurring over a bony prominence or related to medical devices. They are the
result of prolonged or severe pressure with contributions from shear and friction
forces.
Option A: Risk factors for developing pressure injuries, in general, include
immobility, reduced perfusion, malnutrition, and sensory loss. Other
Practice Questions Quiz #4 | 75
Questions
FNDNRS-04-001
All of the following can cause tachycardia except:
A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation
Correct Answer: D. Parasympathetic nervous system stimulation
Parasympathetic nervous system stimulation of the heart decreases the heart rate
as well as the force of contraction, rate of impulse conduction and blood flow
through the coronary vessels. Fever, exercise, and sympathetic stimulation all
increase the heart rate. The parasympathetic nervous system (PNS) releases the
hormone acetylcholine to slow the heart rate. Such factors as stress, caffeine, and
excitement may temporarily accelerate your heart rate, while meditating or taking
slow, deep breaths may help to slow your heart rate.
Option A: Tachypnea and tachycardia develop, and the patient becomes
dehydrated because of sweating and vapor losses from the increased
respiratory rate. Many manifestations of fever are related to the increased
metabolic rate, increased need for oxygen, and use of body proteins as an
energy source.
Option B: Often, ventricular tachycardia will occur during the recovery
period post exercise due to increased levels of adrenaline. In a study
conducted in 1991, it was found that 70% of patients tested experienced
idiopathic ventricular tachycardia as a result of exercise. Exercising for any
duration will increase your heart rate and will remain elevated for as long
as the exercise is continued. At the beginning of exercise, your body
removes the parasympathetic stimulation, which enables the heart rate to
, gradually increase. As you exercise more strenuously, the sympathetic
system “kicks in” to accelerate your heart rate even more.
Option C: Heart rate is controlled by the two branches of the autonomic
(involuntary) nervous system. The sympathetic nervous system (SNS) and
the parasympathetic nervous system (PNS). The sympathetic nervous
system (SNS) releases the hormones (catecholamines – epinephrine and
norepinephrine) to accelerate the heart rate.
FNDNRS-04-002
Palpating the midclavicular line is the correct technique for assessing:
A. Baseline vital signs
B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse
Correct Answer: D. Apical pulse
The apical pulse (the pulse at the apex of the heart) is located on the
midclavicular line at the fourth, fifth, or sixth intercostal space. Assessing whether
the rhythm of the pulse is regular or irregular is essential. The pulse could be
regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along
with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the
pulse rate becomes faster during inspiration and slows down during expiration.
Irregularly irregular pattern is more commonly indicative of processes like atrial
flutter or atrial fibrillation.
Option A: Baseline vital signs include pulse rate, temperature, respiratory
rate, and blood pressure. Vital signs are an objective measurement for the
essential physiological functions of a living organism. They have the name
“vital” as their measurement and assessment is the critical first step for any
clinic evaluation. The first set of clinical examinations is an evaluation of the
vital signs of the patient.
Option B: Blood pressure is typically assessed at the antecubital fossa. The
arm should be supported at the heart level. Unsupported arm leads to 10
mmHg to the pressure readings. The patient’s blood pressure should get
, checked in each arm, and in younger patients, it should be tested in an
upper and lower extremity to rule out the coarctation of the aorta.
Option C: Respiratory rate is assessed best by observing chest movement
with each inspiration and expiration. The respiratory rate is the number of
breaths per minute. The normal breathing rate is about 12 to 20 beats per
minute in an average adult. In the pediatric age group, it is defined by the
particular age group. Parameters important here again include its rate,
depth of breathing, and its pattern rate of breathing is a crucial parameter.
FNDNRS-04-003
The absence of which pulse may not be a significant finding when a patient is
admitted to the hospital?
A. Apical
B. Radial
C. Pedal
D. Femoral
Correct Answer: C. Pedal
Because the pedal pulse cannot be detected in 10% to 20% of the population, its
absence is not necessarily a significant finding. However, the presence or absence
of the pedal pulse should be documented upon admission so that changes can
be identified during the hospital stay. Absent peripheral pulses may be indicative
of peripheral vascular disease (PVD). PVD may be caused by atherosclerosis,
which can be complicated by an occluding thrombus or embolus. This may be
life-threatening and may cause the loss of a limb.
Option A: Apical pulse rate is indicated during some assessments, such as
when conducting a cardiovascular assessment and when a client is taking
certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is
auscultated pre and post medication administration. It is also a best
practice to assess apical pulse in infants and children up to five years of
age because radial pulses are difficult to palpate and count in this
population.
, Option B: Examiners frequently evaluate the radial artery during a routine
examination of adults, due to the unobtrusive position required to palpate
it and it’s easy accessibility in various types of clothing. Like other distal
peripheral pulses (such as those in the feet) it also may be quicker to show
signs of pathology. Palpation is at the anterior wrist just proximal to the
base of the thumb.
Option D: The femoral pulse may be the most sensitive in assessing for
septic shock and is routinely checked during resuscitation. It is palpated
distally to the inguinal ligament at a point less than halfway from the pubis
to the anterior superior iliac spine.
FNDNRS-04-004
Which of the following patients is at greatest risk for developing pressure ulcers?
A. An alert, chronic arthritic patient treated with steroids and aspirin.
B. An 88-year old incontinent patient with gastric cancer who is confined to
his bed at home.
C. An apathetic 63-year old COPD patient receiving nasal oxygen via
cannula.
D. A confused 78-year old patient with congestive heart failure (CHF) who
requires assistance to get out of bed.
Correct Answer: B. An 88-year old incontinent patient with gastric cancer
who is confined to his bed at home.
Pressure ulcers are most likely to develop in patients with impaired mental status,
mobility, activity level, nutrition, circulation and bladder or bowel control. Age is
also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition
(from gastric cancer) and is confined to bed is at greater risk. Pressure injuries are
defined as localized damage to the skin as well as underlying soft tissue, usually
occurring over a bony prominence or related to medical devices. They are the
result of prolonged or severe pressure with contributions from shear and friction
forces.
Option A: Risk factors for developing pressure injuries, in general, include
immobility, reduced perfusion, malnutrition, and sensory loss. Other
