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The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next?
- A. Ask the NAP to retake the blood pressure.
- B. Instruct the NAP to assess the patient's other vital signs.
- C. Disregard the report and have it rechecked at the next scheduled time.
- D. Retake the blood pressure personally and assess the patient's condition
Correct Answer: D
Rationale: Abnormally low BP requires verification and assessment. The nurse retaking it (D) ensures accuracy and allows immediate patient evaluation, overriding NAP data. Retaking by NAP (A) or adding vitals (B) delays RN judgment. Ignoring it (C) risks harm. Choice D is correct, per RN accountability standards.
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The nurse is caring for a patient who reports feeling light-headed and 'woozy.' The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?
- A. Apply more pressure to the radial artery to feel pulse.
- B. Notify the health care provider of the findings.
- C. Tell the patient to expect these symptoms occasionally.
- D. Recheck the vital signs in an hour.
Correct Answer: B
Rationale: Light-headedness, irregular pulse, and a BP drop (100/72 from 113/80) suggest instability (e.g., arrhythmia). Notifying the provider (B) ensures prompt evaluation. More pressure (A) won't clarify irregularity. Dismissing symptoms (C) or delaying (D) risks deterioration. Choice B is correct, per nursing escalation protocols.
What is the primary purpose of pulse assessment?
- A. Assessing changes in blood pressure
- B. Assessing changes in body temperature
- C. Assessing changes in cardiac status
- D. Assessing changes in respiratory status
Correct Answer: C
Rationale: Pulse assessment primarily evaluates cardiac status (C), reflecting heart rate and rhythm, key indicators of cardiovascular function. Blood pressure (A) relates but requires a cuff. Temperature (B) isn't pulse-related. Respiratory status (D) is secondary. Choice C is correct, per nursing fundamentals, as pulse directly monitors heart performance, guiding cardiac care.
A nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.
The nurse needs to obtain an accurate respiratory rate from a patient who is talking with visitors. What will the nurse do?
- A. Tell the patient to continue talking.
- B. Count respirations while the patient is talking.
- C. Obtain without the patient knowing.
- D. Wait until the patient finishes talking.
Correct Answer: C
Rationale: Talking alters respiratory rate, so counting discreetly (C) during conversation ensures an undisturbed baseline. Continuing talking (A) or counting during it (B) skews results. Waiting (D) delays assessment. Choice C is correct, a nursing tactic to capture natural breathing patterns accurately.
A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
- A. A 17-year-old male who has just returned from outside 'for a smoke' who needs a temperature taken.
- B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.
- C. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74.
- D. An 87-year-old male suspected of hypothermia whose temperature is below normal.
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 (B) indicates potential shock or bleeding, a priority. Smoking (A) or pain with stable BP (C) is less urgent. Hypothermia (D) needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.