Procedures - NCLEX-PN
Card 1 of 612
A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?
A nurse takes a patient's blood pressure and records it at 146/92 mmHg. This is the patient's first visit to the clinic and they have no past medical records available. Would this patient be diagnosed with hypertension?
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A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.
A patient with a one-time high blood pressure reading can not be diagnosed as hypertensive. A diagnosis of hypertension requires at least three measurements of blood pressure over 140/90 mmHg on at least two separate visits to health care provider.
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A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
A patient with a blood pressure reading of 168/102 mmHg on three or more occasions would be diagnosed with what stage of hypertension?
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Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.
Stage II hypertension is defined as a blood pressure equal to or greater than 160 mmHg systolic over 100 mmHg diastolic, taken at three different times on at least two separate occasions. Stage I hypertension is systolic blood pressure of 140-160 mmHg or diastolic blood pressure of 90-100 mmHg, while prehypertension is defined as a systolic blood pressure of 120-140 mmHg or diastolic blood pressure of 80-90 mmHg.
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Which of the following is not a normal part of taking a patient's vitals?
Which of the following is not a normal part of taking a patient's vitals?
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While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.
While most examiners remember to take the pulse, temperature, and blood pressure while assessing their patient's vitals, overall visual appearance is also an important part of an individuals vitals. Does the patient appear ill? Anxious? Are there any noticeable issues with hygiene or bizarre dress or movements? Are there any signs of pallor, jaundice, or cyanosis? All of these observations can be quickly noted in a patient's chart when taking vitals.
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The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?
The pulse of your patient is 120 beats per minute. What is the appropriate term for this finding?
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Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.
Tachycardia is the term used to describe a faster than normal heart rate. A heart rate of more than 100 beats per minute is considered tachycardic. Bradycardia is used to describe a slower than normal heart rate. Less than 60 beats per minute is considered bradycardia.
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The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?
The physician on call pages you to ask if the patient you are taking care of is afebrile. Which of the following vital signs would you find in an afebrile patient?
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Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.
Afebrile is a term used to describe a patient who does not have a fever. Clinically, a fever is defined as a temperature greater than 100.4 Fahrenheit. Blood pressure, heart rate, and respiratory rate do not tell you if the patient has a fever.
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A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?
A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?
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A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.
A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.
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Which of the following has been removed from washed red blood cells?
Which of the following has been removed from washed red blood cells?
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Washed red blood cells are the product of blood that has been stripped of plasma, leukocytes, antibodies, cytokines, and platelets, in addition to any other blood proteins.
Washed red blood cells are the product of blood that has been stripped of plasma, leukocytes, antibodies, cytokines, and platelets, in addition to any other blood proteins.
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Washed red blood cells are generally administered to which of the following patient populations?
Washed red blood cells are generally administered to which of the following patient populations?
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Washed red blood cells are generally prepared for patients with a history of severe allergic reaction to blood transfusion. Washed red blood cells are not generally required in patients with kidney disease, patient who are immunocompromised, or patients with metastatic disease.
Washed red blood cells are generally prepared for patients with a history of severe allergic reaction to blood transfusion. Washed red blood cells are not generally required in patients with kidney disease, patient who are immunocompromised, or patients with metastatic disease.
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Before administration, all plasma products must be tested for which of the following?
Before administration, all plasma products must be tested for which of the following?
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Before administration, plasma products must be checked for ABO compatibility and Rh compatibility.
ABO blood type does not have to be an exact match, but blood types must be compatible. An Rh positive individual, for example, is compatible with either Rh negative blood or positive blood, while an Rh negative individual is only compatible with Rh negative blood.
Before administration, plasma products must be checked for ABO compatibility and Rh compatibility.
ABO blood type does not have to be an exact match, but blood types must be compatible. An Rh positive individual, for example, is compatible with either Rh negative blood or positive blood, while an Rh negative individual is only compatible with Rh negative blood.
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After thawing, fresh frozen plasma must be used within which of the following time frames?
After thawing, fresh frozen plasma must be used within which of the following time frames?
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Whenever possible, fresh frozen plasma should be transfused immediately (or as soon as possible) after thawing. However, if this is not possible, it may be refrigerated for as long as 24 hours after thawing.
Whenever possible, fresh frozen plasma should be transfused immediately (or as soon as possible) after thawing. However, if this is not possible, it may be refrigerated for as long as 24 hours after thawing.
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Which of the following might be a sign of a transfusion reaction?
Which of the following might be a sign of a transfusion reaction?
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Common signs of transfusion reaction include urticaria, itching, or swelling, pallor or cyanosis, anxiety, and myalgia, tingling, or numbness, in addition to diaphoresis, tachycardia, headache, and gastrointestinal distress.
Common signs of transfusion reaction include urticaria, itching, or swelling, pallor or cyanosis, anxiety, and myalgia, tingling, or numbness, in addition to diaphoresis, tachycardia, headache, and gastrointestinal distress.
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A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.
Where would the nurse listen to evaluate the pulmonic valve?
A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.
Where would the nurse listen to evaluate the pulmonic valve?
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The pulmonic valve can be auscultated to the left of the sternum at the second intercostal space. Auscultation at this space can aid in the identification of pulmonary murmurs such as pulmonary stenosis or regurgitation. The second right intercostal space is the location at which the nurse would be able to evaluate the aortic valve. The first intercostal space is not generally auscultated in a normal heart exam.
The pulmonic valve can be auscultated to the left of the sternum at the second intercostal space. Auscultation at this space can aid in the identification of pulmonary murmurs such as pulmonary stenosis or regurgitation. The second right intercostal space is the location at which the nurse would be able to evaluate the aortic valve. The first intercostal space is not generally auscultated in a normal heart exam.
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A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.
The nurse pauses to listen at the fifth intercostal space on the left mid-clavicular line. The nurse is evaluating which of the following?
A nurse is performing standard cardiac auscultation on a 47 year old male with normal heart size.
The nurse pauses to listen at the fifth intercostal space on the left mid-clavicular line. The nurse is evaluating which of the following?
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The fifth intercostal space on the left mid-clavicular line is the best location from which to evaluate the mitral valve. The other heart structures are paired with locations as follows:
- Aortic valve: the second intercostal space right of the sternum
- Pulmonic valve: the second intercostal space left of the sternum
- Tricuspid valve: the fourth intercostal space left of the sternum
The fifth intercostal space on the left mid-clavicular line is the best location from which to evaluate the mitral valve. The other heart structures are paired with locations as follows:
- Aortic valve: the second intercostal space right of the sternum
- Pulmonic valve: the second intercostal space left of the sternum
- Tricuspid valve: the fourth intercostal space left of the sternum
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How might an overlarge cuff affect a blood pressure reading?
How might an overlarge cuff affect a blood pressure reading?
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An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.
An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.
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A stethoscope has two components to the chest piece. These are called the and the .
A stethoscope has two components to the chest piece. These are called the and the .
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The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.
The chest-piece of the stethoscope is made up of two components designed for auscultation: the bell and the diaphragm. The bell is dome-shaped and used for auscultation of low-pitched sounds, while the diaphragm is used to auscultate high-pitched sounds.
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The nurse cares for a patient hospitalized for 5 days with pneumonia. He is about to be discharged and the nurse is providing discharge instructions to the patient and the family. Which statement made by the patient’s family should most concern the nurse?
The nurse cares for a patient hospitalized for 5 days with pneumonia. He is about to be discharged and the nurse is providing discharge instructions to the patient and the family. Which statement made by the patient’s family should most concern the nurse?
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When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.
When a patient has an infection and is prescribed antibiotics, the patient should always take the full course of the medication and never discontinue the medication. It is easy for patients to believe they can stop taking the medication when the symptoms are resolved, but the nurse needs to educate the patient to continue the full regimen. The rest of the statements are accurate; the patient must get adequate rest, eat well, use the incentive spirometer, and stay away from others who are sick until he is well.
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A 39-year-old man presents to the ER with weakness, confusion, and vertigo. His heart rate is 91 and bounding, blood pressure is 
, temperature is 
, and blood glucose is 
. He is non-diabetic, he is not on any medication, and he denies recreational drug use. Which of the following is the most likely cause of his symptoms?
A 39-year-old man presents to the ER with weakness, confusion, and vertigo. His heart rate is 91 and bounding, blood pressure is
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The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below 
in a non-diabetic patient. The symptoms of hypoglycemia include altered consciousness, tremors, weakness, vertigo, headaches, heart palpitations, and a bounding pulse.
A temperature of 
is not considered abnormal as it may reflect a normal variation in body temperature.
His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.
It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.
The most likely cause of his symptoms is hypoglycemia, which is defined as a blood glucose below
A temperature of
His blood pressure is slightly elevated, but it is unclear whether this is typical for him or whether this represents a significant change from his normal blood pressure. Regardless it would not likely be sufficiently elevated to cause his symptoms.
It is also possible he may be experiencing a panic attack, but in the presence of his depressed blood sugar (and absence of signs of anxiety), hypoglycemia is the most likely cause of his symptoms.
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Abdominal rigidity and decreased bowel sounds would raise your suspicions of what condition?
Abdominal rigidity and decreased bowel sounds would raise your suspicions of what condition?
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Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.
Abdominal rigidity and decreased bowel sounds are classic signs of peritontis. In addition, the patient will often want to lie very still, as any motion often increases pain. Cystitis, ulcerative colitis, and cholecystitis all may cause significant abdominal tenderness but would not generally result in rigidity or decreased bowel sounds.
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Why are blind finger-sweeps not recommended in infants with foreign objects in their oral cavities or airways?
Why are blind finger-sweeps not recommended in infants with foreign objects in their oral cavities or airways?
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Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.
Blind finger sweeps are not recommended in an infant with airway restriction due to a foreign object because they may inadvertently force the object deeper into the airway. A finger sweep should only be used if the object can be visualized. Injury to the oral cavity would not be a primary concern in the case of airway restriction, and a finger sweep would not be expected to trigger either gasping or vomiting in an infant.
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All of the following are forms of shock except .
All of the following are forms of shock except .
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The four main categories of shock are as follows:
- Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
- Hypovolemic: Due to loss of fluids or hemorrhage.
- Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
- Anaphylactic: Systemic inflammatory response to an allergen.
The four main categories of shock are as follows:
- Cardiogenic: Sudden inability of the heart to pump sufficient blood to the body, most commonly due to acute myocardial infarction.
- Hypovolemic: Due to loss of fluids or hemorrhage.
- Septic: Also known as endotoxic shock. Dangerously low blood pressure as the result of systemic inflammatory response to infection.
- Anaphylactic: Systemic inflammatory response to an allergen.
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