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What four assessments should you make when assessing respirations?
- A. Rate, depth, rhythm, effort
- B. Rate, depth, rhythm, sound
- C. Rate, depth, effort, color
- D. Rate, rhythm, effort, temperature
Correct Answer: A
Rationale: When assessing respirations, evaluate rate (breaths per minute), depth (shallow or deep), rhythm (regular or irregular), and effort (ease or difficulty of breathing).
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What characteristic(s) of the pulse should you always assess?
- A. Length of each beat
- B. Strength
- C. Rate
- D. Depth
- E. Rhythm of the beats
Correct Answer: B,C,E
Rationale: When assessing a pulse, you should evaluate its rate (beats per minute), strength (amplitude), and rhythm (regularity) to determine cardiovascular status.
Describe the first intervention you should perform when a patient faints because of low blood pressure.
- A. Lay the patient flat and elevate legs
- B. Administer oxygen
- C. Give fluids immediately
- D. Take blood pressure again
Correct Answer: A
Rationale: Laying the patient flat and elevating their legs increases venous return to the heart, improving blood pressure and cerebral perfusion in cases of fainting due to hypotension.
When auscultated, the heart sounds should sound muffled and distant.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Normal heart sounds (S1 and S2) should be clear and distinct, not muffled or distant, which may indicate pathology.
If peripheral pulses can be palpated with each cardiac contraction, the pulses are said to be 'perfusing.'
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Palpable peripheral pulses with each cardiac contraction indicate adequate perfusion to the extremities.
There are a total of six vital signs: five objective and one subjective. Four of the five objective vital signs include the blood pressure, temperature, pulse, and respirations. What is the fifth objective vital sign? What is the one subjective vital sign?
- A. Fifth objective: oxygen saturation; Subjective: pain
- B. Fifth objective: pain; Subjective: oxygen saturation
- C. Fifth objective: blood pressure; Subjective: temperature
- D. Fifth objective: pulse; Subjective: respirations
Correct Answer: A
Rationale: Oxygen saturation (SpO2) is the fifth objective vital sign, measured via pulse oximetry. Pain is the subjective vital sign, assessed through patient self-report.