#1
Which vital sign is typically measured first in a clinical assessment?
Temperature
ExplanationTemperature is often the initial vital sign assessed to determine the patient's baseline health status.
#2
Which of the following is a common nursing intervention to prevent pressure ulcers?
Frequent repositioning
ExplanationFrequent repositioning helps redistribute pressure, reducing the risk of pressure ulcers in immobilized or bedridden patients.
#3
Which assessment finding is characteristic of hypovolemic shock?
Cool, clammy skin
ExplanationCool, clammy skin is a common sign of hypovolemic shock due to decreased peripheral perfusion and compensatory vasoconstriction.
#4
What is the primary purpose of the Braden Scale in nursing care?
To evaluate risk for pressure ulcers
ExplanationThe Braden Scale assesses a patient's risk for pressure ulcer development by evaluating factors such as mobility, sensory perception, and moisture.
#5
What is the primary purpose of the RACE acronym in fire safety?
To ensure patient safety during a fire emergency
ExplanationThe RACE acronym (Rescue, Alarm, Contain, Extinguish) provides a systematic approach to ensure the safety of patients and staff during a fire emergency.
#6
What is the primary purpose of assessing capillary refill time in a patient?
Evaluating hydration status
ExplanationCapillary refill time is a quick test used to assess peripheral circulation and can indicate hydration levels.
#7
Which of the following is a common assessment tool used to evaluate pain in non-verbal patients?
FLACC Scale
ExplanationThe FLACC Scale assesses pain in non-verbal patients by evaluating Facial expression, Leg movement, Activity, Cry, and Consolability.
#8
What is the priority action for a nurse when encountering a patient with sudden shortness of breath and cyanosis?
Administer oxygen therapy
ExplanationAdministering oxygen therapy is crucial to address hypoxia and stabilize the patient's respiratory status in cases of sudden shortness of breath and cyanosis.
#9
Which of the following is an appropriate nursing intervention for a patient experiencing anaphylaxis?
Initiating an epinephrine injection
ExplanationEpinephrine injection is a life-saving intervention in anaphylaxis, helping to reverse severe allergic reactions by constricting blood vessels and improving breathing.
#10
What is the primary purpose of the Glasgow Coma Scale (GCS) in neurological assessment?
To assess level of consciousness
ExplanationThe Glasgow Coma Scale is used to assess the patient's level of consciousness by evaluating eye, verbal, and motor responses to stimuli.
#11
Which action should a nurse prioritize when caring for a patient with a nasogastric tube?
Checking tube placement before each feeding
ExplanationEnsuring proper nasogastric tube placement before each feeding helps prevent complications such as aspiration or tissue damage.
#12
In a patient with a chest tube, which finding should be reported immediately?
Sudden cessation of drainage
ExplanationSudden cessation of drainage from a chest tube could indicate a blockage or dislodgement, requiring immediate attention to prevent complications.
#13
During a neurological assessment, which reflex involves tapping the patellar tendon to elicit a response?
Patellar reflex
ExplanationThe Patellar reflex, also known as the knee-jerk reflex, assesses the integrity of the spinal cord and peripheral nerves.
#14
What is the primary goal of nutritional assessment in patients with malnutrition?
To identify nutritional deficiencies
ExplanationNutritional assessment aims to identify deficiencies or excesses in nutrient intake, guiding appropriate dietary interventions to improve the patient's nutritional status.
#15
Which of the following is a potential complication of intravenous therapy?
Infiltration
ExplanationInfiltration occurs when intravenous fluid leaks into surrounding tissue, potentially leading to tissue damage and compromising the effectiveness of therapy.
#16
What is the primary purpose of performing a skin assessment in elderly patients?
To identify risk for pressure ulcers
ExplanationSkin assessment in elderly patients aims to identify factors contributing to pressure ulcer development, allowing for preventive measures to be implemented.
#17
Which of the following is a common complication associated with indwelling urinary catheters?
Increased risk of urinary tract infections
ExplanationIndwelling urinary catheters increase the risk of urinary tract infections due to their presence providing a pathway for microbial entry into the urinary tract.