Nokea
Blood pressure can provide you with information regarding which of the following?
- A. Central nervous system
- B. Cardiovascular system
- C. Integumentary system
- D. Renal system
- E. Fluid status
- F. Infection
Correct Answer: B,D,E
Rationale: Blood pressure reflects cardiovascular function (B), renal function (D) through regulation of blood volume, and fluid status (E) as it affects vascular volume.
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You have just completed an initial shift assessment of your 72-year-old female patient who has congestive heart failure. Which of the following assessment findings causes you the most concern?
- A. Fine papular rash under both breasts
- B. Reports her last BM was 2 days ago
- C. AP 78 regular and distant
- D. Has not voided in 12 hours
- E. Complaints of fatigue
Correct Answer: D
Rationale: Not voiding in 12 hours is concerning in a patient with congestive heart failure, as it may indicate worsening renal perfusion or fluid retention.
You have assessed the patient's pupils by shining a light into both pupils as you learned to assess both pupil reflexes and accommodation response. What acronym would you document that would indicate that all findings were within normal parameters?
- A. PERRLA
- B. PEARL
- C. PERRL
- D. PARLA
Correct Answer: A
Rationale: PERRLA stands for Pupils Equal, Round, Reactive to Light, and Accommodation, indicating normal pupil findings.
The off-going nurse reported to you that one of your patients had been having an irregular pulse for several hours. You plan to assess this patient's heart rate carefully during your initial patient rounds at the beginning of your shift. Which of the following would be the most accurate way to do this?
- A. Palpate a radial pulse in both wrists for 30 seconds
- B. Auscultate the apical pulse for 60 seconds
- C. Take a second nurse with you to palpate the radial pulse at the same time that you auscultate the apical pulse for 60 seconds
- D. Palpate the PMI for a full minute
Correct Answer: B
Rationale: Auscultating the apical pulse for 60 seconds provides the most accurate heart rate, especially for irregular rhythms.
If you hear a shrill, high-pitched, crowing sound coming from the room of a 3-year-old child who has croup, you recognize the ominous sign known as
- A. Crackles
- B. Rhonchi
- C. Wheezes
- D. Pleural friction rub
- E. Stridor
Correct Answer: E
Rationale: Stridor is a high-pitched, crowing sound associated with upper airway obstruction, common in croup.
Describe the assessments that you will perform to establish the status of his renal system and ensure that he is not getting into fluid overload problems.
- A. Urine output, weight, edema, breath sounds
- B. Blood pressure, serum creatinine, BUN
- C. Fluid intake, electrolyte levels, lung auscultation
- D. All of the above
Correct Answer: D
Rationale: Renal system assessment includes urine output, weight, edema, breath sounds, blood pressure, serum creatinine, BUN, fluid intake, and electrolyte levels to monitor for fluid overload.