The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Answer and Explanation

The Correct Answer is D

A.   A score of 7 would indicate a much lower level of consciousness and require urgent intervention.
B.   A score of 12 would indicate some level of impairment, with the patient not fully alert or responsive.
C.   A score of 10 would indicate some level of impairment, with the patient not fully alert or responsive.
D.   A score of 15 on the Glasgow Coma Scale indicates full consciousness and normal neurological function. It is the highest possible score, reflecting a patient who is awake, aware, and able to follow commands.

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Correct Answer is A

Explanation

A. Pulse oximetry works by using light absorption to measure the oxygen saturation of hemoglobin in the blood, which typically occurs through the capillary bed in areas like the finger or earlobe.
B. The pulse oximeter does not measure the amount of blood passing through the sensor directly, but rather the oxygen content of the blood.
C. The pulse oximeter does not assess the warmth of the skin as a mechanism for measuring oxygenation.
D. Pulse oximeters measure oxygen saturation levels, not the respiratory rate or blood pressure.

A. respirations gradually decreasing in rate and depth. B. rapid wheezing respirations for two or three breaths with short periods of apnea. C. a breathing pattern of dyspnea followed by a short period of apnea. D. quick shallow respirations with long periods of apnea.

Correct Answer is C

Explanation

A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

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The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 170/90 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as:

If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?

When a fever begins to come down. the patient is in a state of

A patient is receiving an opiate-based medication to help mange pain. Which assessment has the highest priority when monitoring his condition?

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

A 52-year-old patient presents with malaise, fatigue, chest congestion, and a chronic cough. While collecting assessment data, an important question to ask is

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:

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: