Question 15
Type: MCSA
In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to
moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the
pressure from the sphygmomanometer?
1. When the cuff is applied
2. When the cuff is being deflated
3. When the first pulsation is felt
4. When the second pulsation is felt
Question 16
Type: MCSA
Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the client’s
status?
1. Altered level of consciousness
2. Decreased urine output
3. Irregular radial pulse
4. Toes cool to touch
Question 17
Type: MCSA
When assessing a client’s oxygen saturation reading, the nurse realizes that what will affect this reading?
1. Activity
2. Environmental conditions
3. Nutrition
4. Skin color
Question 18
Type: MCSA
As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do?
1. Allow the client to take some extra deep breaths.
2. Continue to suction but only intermittently.
3. Keep the catheter in place and wait a few minutes.
4. Stop suctioning and give supplemental oxygen.
Question 19
Type: MCSA
The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the
UAP?
1. Cardiac catheterization client returning to the nursing unit
2. COPD client on 2 Lpm oxygen via nasal cannula
3. Pneumonia client nearing discharge
4. Post-op client of 2 days from gallbladder surgery
Question 20
Type: MCMA
Prior to assessing a client’s blood pressure, the nurse reviews factors that could affect the reading. Which factors
could impact blood pressure?
Standard Text: Select all that apply.
1. Stress
2. Race
3. Obesity
4. Medications
5. Employment
Question 21
Type: MCMA
The nurse is planning to assess a client’s pulse. What characteristics should the nurse include in this assessment?
Standard Text: Select all that apply.
1. Rate
2. Rhythm
3. Volume
4. Tone
5. Viscosity
Question 22
Type: MCMA
When assessing a client’s respirations, the nurse realizes that the respiratory centers and chemoreceptors respond
to changes in which factors?
Standard Text: Select all that apply.
1. Oxygen concentration
2. Carbon dioxide concentration
3. Hydrogen ions
4. Potassium level
5. Serum calcium level
Question 23
Type: MCMA
Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these
assessments independently in which situations?
Standard Text: Select all that apply.
1. Client who complains of chest pain
2. Client returning from surgery
3. Prior to administering a medication that affects blood pressure
4. Client who complains of dizziness after ambulating.
5. Client being admitted to the care area
Question 24
Type: MCSA
When documenting a client’s axillary temperature on the graphic sheet, how should the nurse identify the method
of assessing the temperature?
1. AX
2. O
3. R
4. SL
Question 25
Type: MCSA
The nurse assesses phase 1 Korotkoff’s sound occurring at 136 and phase 5 Korotkoff’s sound occurring at 72.
How should the nurse document this client’s blood pressure reading?
1. 136/72
2. 72/136
3. 136 – 72
4. 72 – 136
Question 26
Type: MCMA
A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the
nurse use to determine if this client is experiencing heat stroke?
Standard Text: Select all that apply.
1. Delirious
2. Pale and dizzy
3. Skin warm and flushed
4. No evidence of sweating
5. Had been playing tennis in the sun
Question 27
Type: MCMA
The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure
measurements. What did the nurse observe to make this clinical decision?
Standard Text: Select all that apply.
1. The valve on the bulb was closed.
2. The client was sitting with the legs crossed.
3. The arm was below the level of the heart.
4. The UAP waited 2 minutes before re-measuring.
5. The cuff bladder was placed over the brachial artery.