A nurse caring for a patient on bed rest with a history of respiratory health problems should:

auscultate for bowel sounds once a shift.

auscultate lung sounds at the beginning of a shift.

monitor for skin turgor every shift.

monitor peripheral pulses once a shift.

Answer and Explanation

The Correct Answer is B

A.   Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B.   Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C.   Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D.   Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. A significant drop in blood pressure when standing (typically greater than 20 mm Hg systolic or 10 mm Hg diastolic) is a hallmark of orthostatic hypotension.
B. Dizziness upon standing is a classic symptom of orthostatic hypotension due to decreased blood flow to the brain.
C. Blurred vision can also result from decreased blood flow and is a common symptom of orthostatic hypotension.
D. Syncope (fainting) can occur as a result of orthostatic hypotension when the brain does not receive enough oxygenated blood due to the drop in blood pressure.

A. dilation reflex. B. brisk reflex, C. accommodation. D. consensual reflex

Correct Answer is D

Explanation

A. The dilation reflex refers to pupils dilating in response to dim light, not constricting.
B. A brisk reflex is an expected response, but it does not describe the bilateral pupil constriction when light is shone in one eye.
C. Accommodation refers to the process of the eyes adjusting focus for near vision, not pupil constriction in response to light.

D. Consensual reflex is when both pupils constrict in response to light shined in either one of the eyes, indicating normal neurological function.

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A nurse caring for a patient on bed rest with a history of respiratory health problems should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

Correct Answer is D

Explanation

If dehydration occurs, the blood pressure will

The nurse taking an apical pulse would place the stethoscope at:

The normal pattern of breathing is described as

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

A critically ill patient has faster and deeper, then slower, respirations. These are followed by a period of no breathing for 21 seconds with continuation of this cycle. This respiratory pattern is

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is: