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 C

Explanation

A. Waiting 30 minutes is unnecessary unless there is concern about an acute change in the patient's condition.
B. While both readings can be recorded, the difference between arms should be noted, as it can indicate underlying issues such as vascular problems.

C. It is important to retake the blood pressure on both arms to verify accuracy and check for any significant discrepancy.
D. Retaking the pressure on just one arm may miss important information about the other arm's readings.

A. the state of consciousness. B. if the shape is regular. C. whether one pupil is larger than the other. D. if they have become smaller.

Correct Answer is C

Explanation

A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.

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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

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