The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Answer and Explanation

The Correct Answer is D

A.   A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B.   A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C.   A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D.   A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

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Correct Answer is C

Explanation

A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

A. date of previous diagnostic tests B. where the patient is living C. treatment for previous illnesses D. any allergies to medications

Correct Answer is D

Explanation

A. The date of previous diagnostic tests may be important, but it is secondary to immediate safety concerns like allergies.
B. Information about the patient's living situation can be useful for discharge planning but is not the most urgent piece of information.
C. Previous treatment for illnesses is important but does not supersede immediate health threats like allergies.
D. Knowing any allergies to medications is critical to avoid potentially harmful reactions. This is a priority when beginning care, as it informs medication administration and treatment options.

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The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse taking an apical pulse would place the stethoscope at:

Correct Answer is C

Explanation

When performing an initial assessment on a patient, which piece of information is of highest priority?

Correct Answer is D

Explanation

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories?

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

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:

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

A very pertinent part of the physical examination on a patient with back pain is