Ivytech Fundamental Proctored Exam 2 Practice Questions

A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

A nurse is caring for a large group of patients. She checks on her post-op patient and starts the IV fluids. While programing the pump the nurse is interrupted by another staff member. Three two hours later the nurse rounds and finds that the patient is short of breath, requiring more oxygen and has crackles in her lungs.

The nurse then realizes that the IV fluids were running at twice the ordered rate. What should the nurse do next?

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous.

The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name.

What level of consciousness would the nurse document?

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is?

What is the appropriate response by the instructor?

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?