Name:___________________________________

Nursing 44

1. Blood pressure cuffs come in different sizes, and the blood pressure measurement is not
accurate unless the proper sized cuff is used. A cuff that is too narrow/short will result in a -
_________________reading, while a cuff that is too wide will result in a _________________reading.

2. Mrs. Malone is admitted with pneumonia. Her vital signs are: BP 112/64 mm Hg, HR 102, RR
26, tympanic temperature 37.9° C (100.2° F). What vital sign requires immediate attention?
A. Heart rate
B. Pulse pressure
C. Respiratory rate
D. Temperature

3. In assessing the abdomen, which of the following is the correct sequence of the physical
assessment?
A. Inspection, Auscultation, Percussion, Palpation
B. Palpation, Auscultation, Percussion, Inspection
C. Inspection, Palpation, Auscultation, Percussion
D. Inspection, Auscultation, Palpation, Percussion

4. The __________ is the best indicator of overall kidney function.

5. What are the two values for Hematocrit and Hemoglobin indicate a patient may be in need of
a blood transfusion?

6. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the
nurse measures his hourly urine output. She should notify the physician if the urine output is:
A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

7. Following surgery, G.R. complains of mild incisional pain while performing deep- breathing
and coughing exercises. The nurse’s best response would be:
A. “Pain will become less each day.”
B. “This is a normal reaction after surgery.”
C. “With a pillow, apply pressure against the incision.”
D. “I will give you the pain medication the physician ordered.”

8. Antiembolism stockings are used primarily to:

A. Promote venous circulation
B. Provide external warmth
C. Prevent dependent edema
D. Hold foot dressings
9. The patient has had an NG tube for 2 days and is complaining about abdominal pain and
severe nausea. The NG output has decreased over the past 3 hours, and the nurse is concerned
that the tube is not draining properly. What is the nurse's next action?
A. Irrigate the tube with saline and withdraw the instilled fluid.
B. Notify the health care provider.
C. Turn the patient to his left side to promote drainage.
D. Withdraw the tube 5 to 7.5 cm (2 to 3 inches).
10. What two vital signs are important to have before administering antihypertensive
medications?

11. A 59-year-old man has presented to the emergency department with chest pain. Which of
the following components of his subsequent blood work is most clearly indicative of a
myocardial infarction (MI)?
A. CK-MB
B. Troponin
C. Myglobin
D. C-Reactive Protein

12. Which of the following urinalysis results would the nurse recognize as an abnormal finding?
A. pH 6.0
B. WBC 9/hpf
C. Amber yellow color
D. Specific gravity 1.025

13. The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four
of your patients. Which patient do you need to assess first?
A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72
C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84
D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

14. A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has
a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his
admitting vital signs. Which measurement should you reassess? (Select all that apply.)
A. Right arm BP: 120/80
B. Radial pulse rate: 72 and irregular
C. Temporal temperature: 37.4° C (99.3° F)
D. Respiratory rate: 28
E. Oxygen saturation: 99%

15. A patient is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg
tablets. How many tablets does the nurse administer?
A. ½ tablet
B. 1 tablet
C. 1½ tablets
D. 2 tablets

16. The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you
program into the infusion pump?
A. 125 mL/hr
B. 167 mL/hr
C. 200 mL/hr
D. 1000 mL/hr

17. Which of the following signs or symptoms in an opioid-naive patient is of greatest concern
to the nurse when assessing the patient 1 hour after administering oxycodone?
A. Oxygen saturation of 95%
B. Difficulty arousing the patient
C. Respiratory rate of 10 breaths/min
D. Pain intensity rating of 5 on a scale of 0 to 10
18. A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back
pain. Because of this order, the nurse anticipates an order for which class of medication?
A. Stool softener
B. Stimulant laxative
C. H2 receptor blocker
D. Proton pump inhibitor

19. The nurse notices that a patient has received oxycodone/acetaminophen (Percocet)
(5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most?
A. The patient's level of pain
B. The potential for addiction
C. The amount of daily acetaminophen
D. The risk for gastrointestinal bleeding

20. A male patient returned from the operating room 6 hours ago with a cast on his right leg. He
has not yet voided. Which action would be the most beneficial in assisting the patient to void?
A. Suggest he stand at the bedside
B. Stay with the patient
C. Give him the urinal to use in bed
D. Tell him that, if he doesn't urinate, he will be catheterized

21. A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the
nurse anticipate the patient to have?
A. Red
B. Black
C. Green
D. Orange

22. You have been given the following postoperative patients to care for on your shift. Based on
the information provided, which patient should you see first?
A. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the
surgical site, with a heart rate of 92
B. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous
patient-controlled analgesia (PCA). The pulse oximeter has been alarming and reading 85%
C. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her
postoperative dose of antibiotic
D. A 48-year-old following total knee replacement who needs help repositioning in bed

23. A patient is admitted through the emergency department for multisystem trauma following
a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures.
He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures
and external fixator to his unstable pelvic fracture. Interventions that are necessary for
prevention of venous thromboembolism in this high-risk postsurgical patient include: (Select all
that apply.)
A. Intermittent pneumatic compression stockings.
B. Vitamin K therapy.
C. Subcutaneous heparin or enoxaparin (Lovenox).
D. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times
higher than baseline.

24. A patient is receiving a loop diuretic. The nurse should be alert for which symptoms?
A. Restlessness and agitation
B. Paresthesias and irritability
C. Weak, irregular pulse and poor muscle tone
D. Increased blood pressure and muscle spasms

25. When collecting subjective data related to the cardiovascular system, which of the following
should be obtained from the patient (select all that apply)?
A. Annual income
B. Smoking history
C. Number of pillows used to sleep
D. Blood for basic laboratory studies

26. Data regarding mobility, strength, coordination, and activity tolerance are important for the
nurse to obtain because
A. Many neurologic diseases affect one or more of these areas.
B. Patients are less able to identify other neurologic impairments.
C. These are the first functions to be affected by neurologic disease.
D. Aspects of movement are the most important function of the nervous system.

27. While assessing the adult patient's lungs, the nurse identifies the following assessment
findings. Which finding should be reported to the health care provider?
A. Respiratory rate: 18
B. Heart rate: 90
C. Chest pain: 6/10
D. Oxygen saturation: 92%