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Practice Exam 388 Exam.
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Practice Exam 388 Exam.
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Practice Exam 388 ExamA nurse speaks to the previous nurse on the shift about the patient she is about to
receive. Which stage of the nurse patient relationship is this?
a. pre interaction
b. orientation
c. working
d. termination
e. assessment - ANS-a
A nurse should use soap and water to wash hands instead of alcohol based during
which of the following situations? Select all that apply.
a. After using the bathroom
b. After taking a patients pulse
c. After known exposure to Bacillus anthracis
d. Coming in contact with non-intact skin
e. Before and after removing gloves - ANS-A and C
Describe the importance of hand hygiene: - ANS-Hand hygiene decreases the spread of
deadly germs to patients and decreases health care provider colonization. Also, it
decreases healthcare associated infections.
Describe at least 5 times nurses should practice hand hygiene - ANS-Before eating,
after using the bathroom, after coughing or blowing nose, before and after direct contact
with patients intact skin, after contact of objects in the patients vicinity, moving hands
from contaminated site to uncontaminated sit, before applying and after removing
gloves, after contact with blood, body fluids or excretions, mucous membrane,
non-intact skin, or wound dressings
Which of the following is a time where a nurse should don gloves? Select all that apply
a. Dealing with intact skin
b. Actual or risk of exposure to patient's blood or bodily fluid
c. If the patient is in precautions
d. Before taking vital signs or patient
e. Dealing with non-intact skin or mucous membrane - ANS-B, C, and E
Describe the importance of measuring vital signs. - ANS-Vital signs allow you to get a
baseline of your patient, observe trends, can indicate illness, can help indicate a
, treatment plan, can tell you how a patient is responding to meds, and is an early
indicator of an issue
Which of the following is correct in it's relationship to vital sign variation?
a. Heart rate decreases when the client is stressed or anxious
b. BP is higher during the night and is lower between 10am and 6pm
c. Exercise can reduce BP for several hours following the activity, but during exercise
BP increases because the O2 demand increases
d. African Americans tend to have a lower blood pressure than the average patient -
ANS-C
Select all the situations where the vital signs are out of range for their age group.
a. A newborn baby with a respiratory rate of 45 breathes per minute
b. An adult with a heart rate of 45 beats per minute
c. A teenage with a blood pressure of 130/80
d. A 4 year old with a respiratory rate of 35 breathes per minute - ANS-B and D
Which of these vitals is the most concerning for a 45 year old adult.
a. Heart rate of 105bpm
b. Temperature of 39.5 C
c. Respiratory rate of 22
d. Blood pressure of 122/88mmHg - ANS-B. Temperature is likely to cause change in
the rest of the vitals
Which is correct about collecting a rectal temperature? Select all that apply.
a. Insert probe into anus 1-1.5in for adults
b. Rectal temp is the best temperature to take for infants
c. Insert probe ¼ to ½ inch into anus for children
d. Add 1 degree to reading since it is not a core temp - ANS-A and C
The radial pulse is 65bpm and the simultaneous apical pulse is 77bpm, what is the
pulse deficit? - ANS-12bpm
Describe at least three ways an inaccurate measurement of blood pressure can be
achieved. - ANS-Cuff too big or too small, client was wearing clothes under the cuff, arm
is positioned above heart level, insufficient time between measurements
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