Question 1

A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?*

A. Temperature

B. Pulse

C. Respiratory rate

D. Blood pressure

Question 2

Prioritize your nursing interventions based on the vital signs.*

A. Temperature 102.4°F (39.1°C), oral, electronic thermometer

B. Heart rate 130 beats/min, apical

C. Respiratory rate 25 breaths/min

D. BP 145/80

Question 3

A client is admitted with a head injury and may develop neurogenic fever. Which nursing diagnosis would be most appropriate for this client?*

A. Risk for imbalanced body temperature

B. Hyperthermia

C. Hypothermia

D. Ineffective thermoregulation

Question 4

According to the JNC’s seventh report, a BP reading of 144/96 would be considered ______.*

A. Normal

B. Prehypertension

C. Stage 1 hypertension

D. Stage 2 hypertension

Question 5

Developing a trusting provider-client relationship encourages the client to ______.*

A. Talk about his or her feelings and needs

B. Take his or her medicines

C. Live a productive life

D. Maintain a positive attitude toward his or her illness

Question 6

Which of the following nursing actions is therapeutic for dying clients?*

A. Apply nursing presence.

B. Avoid the use of touch.

C. Discuss only issues over which the client has control.

D. Limit family visits in order to conserve client energy.

Question 7

A client who has just learned that she is terminally ill with breast cancer says, ‘‘Not me. This can’t be happening to me!’’ Which stage of death and dying as described by Ku¨bler-Ross is this client exhibiting?*

A. Anger

B. Bargaining

C. Denial

D. Depression

Question 8

The nurse is providing postmortem care for a client. Which of the following interventions would be appropriate prior to allowing the family to visit?*

A. Call the prescribing practitioner to verify the time of death before allowing the family to see the body.

B. Keep the sheet over the client’s face until the family is comfortably seated in the room.

C. Prepare the body to look as clean and natural as possible.

D. Wear sterile gloves to pack the anal canal with gauze.

Question 9

The measurement of blood that enters the aorta with each ventricular contraction is called the ______.*

A. Pulse

B. Stroke volume

C. Cardiac output

D. Pulse pressure

Question 10

A client is admitted to the hospital and is in the terminal stage of cancer. The nurse enters the client’s room to administer some medicine and finds the client crying. Which of the following is the most therapeutic nursing action?*

A. Administer the client’s medication and leave so the client can cry in private.

B. Call the family to come to the hospital to stay with the client.

C. Sit down and hold the client’s hand.

D. Tell the client that you will call the client’s minister.

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