Question 1
Situation: A client was rushed to the Emergency Room and you are his attending nurse. You are assessing the vital signs.
After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP.
The nurse finds that the cuff is too narrow and this will cause the BP reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be
Situation: A client was rushed to the Emergency Room and you are his attending nurse. You are assessing the vital signs.
After a few hours in the emergency room, the client is admitted to the ward with an order of hourly monitoring of BP.
The nurse finds that the cuff is too narrow and this will cause the BP reading to be:
A. Inconsistent
B. Low systolic and high diastolic
C. Higher than what the reading should be
D. Lower than what the reading should be
Answer
C. Higher than what the reading should be
Question 2
You attached a pulse oximeter to the client. You know that the purpose of this is to:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s antihypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
You attached a pulse oximeter to the client. You know that the purpose of this is to:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s antihypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
Answer
D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops
Question 3
Through the client’s health history, you found out that the patient smokes and drinks coffee. When taking the BP of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s BP for accurate reading?
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 1 hour
Through the client’s health history, you found out that the patient smokes and drinks coffee. When taking the BP of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s BP for accurate reading?
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 1 hour
Answer
C. 30 minutes
Question 4
While the pulse oximeter is on the client’s fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to:
A. Turn on and set the alarm of the oximeter
B. Do nothing since there are no identified problems
C. Cover the fingertip sensor with a towel or bed sheet
D. Change the location of the sensor every four hours
While the pulse oximeter is on the client’s fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to:
A. Turn on and set the alarm of the oximeter
B. Do nothing since there are no identified problems
C. Cover the fingertip sensor with a towel or bed sheet
D. Change the location of the sensor every four hours
Answer
C. Cover the fingertip sensor with a towel or bed sheet
Question 5
You are to assess the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature?
A. 10 minutes
B. 15 minutes
C. 20 minutes
D. 30 minutes
You are to assess the temperature of the client the next morning and found out that he ate ice cream. How many minutes should you wait before assessing the client’s oral temperature?
A. 10 minutes
B. 15 minutes
C. 20 minutes
D. 30 minutes
Answer
D. 30 minutes
Question 6
Situation: Oral care is an important part of hygienic practices and promoting client comfort.
When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on side-lying position with head of bed lowered
B. Keep the patient dry by placing a towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression
Situation: Oral care is an important part of hygienic practices and promoting client comfort.
When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
A. Put the client on side-lying position with head of bed lowered
B. Keep the patient dry by placing a towel under the chin
C. Wash hands and observe appropriate infection control
D. Clean mouth with oral swabs in a careful and an orderly progression
Answer
A. Put the client on side-lying position with head of bed lowered
Question 7
Situation: Oral care is an important part of hygienic practices and promoting client comfort.
A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to the lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked in mouthwash to avoid rinsing the buccal cavity
B. Swabbing the inside of the cheeks and lips, tongue, and gums with dry cotton swabs
C. Use finger wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums
D. Suctioning as needed while cleaning the buccal cavity
Situation: Oral care is an important part of hygienic practices and promoting client comfort.
A possible problem while providing oral care to unconscious clients is the risk of fluid aspiration to the lungs. This can be avoided by:
A. Cleaning teeth and mouth with cotton swabs soaked in mouthwash to avoid rinsing the buccal cavity
B. Swabbing the inside of the cheeks and lips, tongue, and gums with dry cotton swabs
C. Use finger wrapped with wet cotton washcloth to rub inside the cheeks, tongue, lips and gums
D. Suctioning as needed while cleaning the buccal cavity
Answer
D. Suctioning as needed while cleaning the buccal cavity
Question 8
Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:
A. Salt solution
B. Water
C. Petroleum jelly
D. Mentholated ointment
Your client has difficulty of breathing and is mouth breathing most of the time. This causes dryness of the mouth with unpleasant odor. Oral hygiene is recommended for the client and in addition, you will keep the mouth moistened by using:
A. Salt solution
B. Water
C. Petroleum jelly
D. Mentholated ointment
Answer
B. Water
Question 9
A nurse is observed taking all of the following actions when suctioning a patient who has a newly placed tracheostomy tube. Which of the following actions require intervention?
A. Applying suction for less than 15 seconds at one time
B. Administering 100% oxygen prior to starting suctioning
C. Utilizing negative pressure of 120 mmHg during suctioning
D. Deflating tracheostomy cuff for three minutes before initiating suction
A nurse is observed taking all of the following actions when suctioning a patient who has a newly placed tracheostomy tube. Which of the following actions require intervention?
A. Applying suction for less than 15 seconds at one time
B. Administering 100% oxygen prior to starting suctioning
C. Utilizing negative pressure of 120 mmHg during suctioning
D. Deflating tracheostomy cuff for three minutes before initiating suction
Answer
D. Deflating tracheostomy cuff for three minutes before initiating suction
Question 10
The major difference between an antiseptic and a disinfectant is that an antiseptic:
A. Destroys pathogenic and non-pathogenic microorganisms
B. Inhibits microbial growth on skin
C. Has a shorter duration of effectiveness
D. Destroys pathogens
The major difference between an antiseptic and a disinfectant is that an antiseptic:
A. Destroys pathogenic and non-pathogenic microorganisms
B. Inhibits microbial growth on skin
C. Has a shorter duration of effectiveness
D. Destroys pathogens
Answer
B. Inhibits microbial growth on skin
