A nurse caring for a patient on bed rest with a history of respiratory health problems should:

auscultate for bowel sounds once a shift.

auscultate lung sounds at the beginning of a shift.

monitor for skin turgor every shift.

monitor peripheral pulses once a shift.

Answer and Explanation

The Correct Answer is B

A.   Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B.   Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C.   Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D.   Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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Correct Answer is B

Explanation

Pulse pressure is calculated as the difference between systolic and diastolic blood pressure. 170 - 90 = 80 mm Hg, so the pulse pressure would be 80mmHg.

A. "You stand 20 feet away from the chart while I test each of your eyes." B. The number beside the largest print read is your visual acuity score! C. "I will be testing your vision with your reading glasses on." D. "You stand 50 feet away from the chart while I test each of your eyes."

Correct Answer is A

Explanation

A. The patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

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A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

Correct Answer is B

Explanation

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Correct Answer is A

Explanation

A 52-year-old patient presents with malaise, fatigue, chest congestion, and a chronic cough. While collecting assessment data, an important question to ask is

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The nurse taking a blood pressure should:

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Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?