N258 Exam 1 Practice

The nurse is assessing her patient for their heart rate. The nurse understands that an expected range of heart rate for an adult is which of the following?

• 50-80

• 60-100

• 40-90

• 70-110

When preparing to enter the assessment room of an adolescent patient, which of the following considerations does the nurse need to recall for the physical assessment of this population?

• The nurse can talk to them as candidly and openly as they would an adult.

• The adolescent should be allowed to remain in their clothes for the examination.

• The adolescent likes to be of "help" to the nurse during the examination.

• It is important for the parent to stay in the room during the assessment because they are of minor age.

When preparing to assess the respiratory rate of an infant, the nurse understands that she should count for how long?

• 30 seconds and take the number times 2

• 15 seconds and take the number times 4

• 1 minute and do not multiply by anything

• 20 seconds and multiply the number times 3

The nurse has a student nurse with them for the day and is instructing them on how to take a manual blood pressure. The nurse is accurate in explaining that prior to applying the blood pressure cuff, the student nurse needs to palpate which artery?

• Radial Artery

• Posterior Tibialis Artery

• Popliteal Artery

• Brachial Artery

When donning PPE, the nurse understands that which of the following is applied last in the process?

• Mask

• Goggles

• Gown

• Gloves

Place the following assessment techniques in the correct order (from left to right) that the nurse will follow when assessing the respiratory system.

• Percussion

• Inspection

• Palpation

• Auscultation

During the respiratory assessment, the nurse places her hand palmar base of the fingers on the patient's back and asks them to say the phrase "99" repeatedly. What is the nurse assessing for?

• Adventitious lung sounds

• Symmetrical chest expansion

• Vocal crepitus

• Tactile Fremitus

While completing handwashing, the nurse is knowledgeable of the appropriate process by demonstrating rubbing the hands together with soap and friction, outside of the water, for how long?

• 15 seconds

• 30 seconds

• 45 seconds

• 20 seconds

1. Which of the following narrative nursing notes is the most correct? 

• 1. 0910 Vital signs taken and documented in the flowsheet. Education provided on QD activity plan with physical therapy and occupational therapy while in the hospital. Patient now resting in bed with call light in reach.  

• 1. Patient found lying on the floor by the bed. Patient stated, “I fell when reaching for my water on the bedside table.” Vital signs obtained and documented in the flowsheet. Physician notified. ------------------------------------------S Krupp, RN 

• 1. 1037 Patient heart rate increased to 135 beats per minute. The physician was called and notified of this patient status change. Patient states, “I feel fine” and denies any pain or dizziness. Orders will be inputted by physician.  --------------------------S Krupp, RN 

• 1. 1115 Patient is sleeping. ----------------------------------- S Krupp, RN  

1. Which of the following best describes the purpose of a functional health assessment? 

• 1. It assesses how the patient is coping with life at home. 

• 1. It determines if a child is meeting developmental milestones.  

• 1. It can identify any problems with memory that the patient may be experiencing. 

• 1. It is important to determine how they are managing day-to-day activities of daily living.