The nurse observes a nursing student taking blood pressure (BP) on a patient.

The nurse notes

that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP
range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings
made by the student is most likely caused by an incorrect technique?

A. 96/40 mm Hg
B. 110/66 mm Hg
C. 130/90 mm Hg
D. 156/82 mm Hg

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 a 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

A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit
after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An
intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression
stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which
sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and
temperature?

A. Right antecubital and tympanic membrane

B. Right popliteal and rectal
C. Left antecubital and oral
D. Left popliteal and temporal artery

Which of the following patients are at most risk for tachypnea?

Select all that apply.
A. Patient just admitted with four rib fractures
B. Woman who is 9 months’ pregnant
C. Adult who has consumed alcoholic beverages
D. Adolescent waking from sleep
E. Three-pack–per-day smoker with pneumonia
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His
medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F)
(0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How
would you describe this pattern of temperature measurements?

A. Usual range of circadian rhythm measurements

B. Sustained fever pattern
C. Intermittent fever pattern
D. Resolving fever pattern

As you are obtaining the oxygen saturation on a 19-year-old college student with severe
asthma, you note that she has black nail polish on her nails. You remove the polish from one
nail, and she asks you why her nail polish had to be removed. What is the best response?

A. Nail polish attracts microorganisms and contaminates the finger sensor.

B. Nail polish increases oxygen saturation.
C. Nail polish interferes with sensor function.
D. Nail polish creates excessive heat in sensor probe.

The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine
on the patient who has recently returned from surgery following removal of her gallbladder is
flashing a blood pressure of 65/46 and alarming. What is the correct order for care
activities? 1. Press the start button of the electronic blood pressure machine to obtain a new
reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient’s pulse
distal to the blood pressure cuff. 4. Assess the patient’s mental status. 5. Remind the patient not
to bend her arm with the blood pressure cuff.
A. 5, 3, 1, 4, 2
B. 3, 2, 1, 4, 5
C. 4, 1, 3, 2, 5
D. 1, 2, 4, 3, 5
E. 2, 3, 1, 4, 5

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep
breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on
admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen
saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a
positive outcome of the oxygen therapy?

A. Temperature: 37° C (98.6° F)

B. Radial pulse: 112
C. Respiratory rate: 24
D. Oxygen saturation: 96%