Audible stridor indicates airway compromise. Detection of abnormal airway sounds, such as stridor, suggests airway compromise and requires immediate intervention. The other answer options are findings from the breathing component of the primary assessment.
Question 2
Which condition could cause a widening pulse pressure?
Cardiac tamponade
Vasodilation
✓
Vasoconstriction
Hypovolemia
Correct Answer
Vasodilation
Vasodilation causes a widening pulse pressure by decreasing diastolic pressure while systolic pressure remains relatively unchanged. Vasoconstriction, hypovolemia, and cardiac tamponade typically result in a narrowing pulse pressure.
Question 3
Which finding is considered subjective data?
The patient has a blood pressure of 90/60 mm Hg.
Bruising is noted on the right occiput.
A family member states that the patient has a history of seizures.
✓
Auscultation reveals audible wheezes.
Correct Answer
A family member states that the patient has a history of seizures.
Subjective data includes information provided by the patient or family members that cannot be directly observed or measured by the nurse. The other options are objective data obtained through observation, auscultation, or measurement.
Question 4
Which abnormal finding can be detected during the secondary assessment?
Airway obstruction
Altered level of consciousness
Friction rub
✓
Absent peripheral pulses
Correct Answer
Friction rub
A friction rub is an abnormal finding detected during the secondary assessment through auscultation. Airway obstruction, absent peripheral pulses, and altered level of consciousness are findings identified during the primary assessment.
Question 5
For a patient with severe sternal retractions, which intervention is the priority?
Administer supplemental oxygen.
Obtain arterial blood gas levels.
Position the patient to maximize ventilation.
✓
Prepare for endotracheal intubation.
Correct Answer
Position the patient to maximize ventilation.
Positioning the patient to maximize ventilation is the priority intervention for a patient with severe sternal retractions. This is a basic airway and breathing intervention that should be performed before more invasive procedures.
Question 6
For which patients do baseline arterial blood gas levels (ABGs) reveal compensated respiratory alkalosis and hypocapnia?
Bariatric
Obstetric
✓
Geriatric
Pediatric
Correct Answer
Obstetric
Obstetric patients normally have compensated respiratory alkalosis and hypocapnia due to progesterone-stimulated hyperventilation during pregnancy. This is a normal physiologic change of pregnancy that should be considered when interpreting ABG results.
Question 7
An infant is prone to which problem?
Hypothermia
Hypertension
Bradycardia
Gastric distention
✓
Correct Answer
Gastric distention
In infants, gastric distention results from swallowed air during crying. This is a common finding in infants that can impair diaphragmatic excursion and compromise ventilation. The nurse should consider gastric decompression if distention is significant.
Question 8
An obstetric patient is prone to which airway problem?
Laryngospasm
Nosebleeds
✓
Foreign body aspiration
Epiglottitis
Correct Answer
Nosebleeds
Obstetric patients are prone to nosebleeds (epistaxis) due to increased vascularity of the nasal mucosa during pregnancy. The increased blood volume and vasodilation that occur during pregnancy contribute to engorgement of the nasal mucosa.
Question 9
Which finding requires priority intervention?
Blood pressure is 100/70 mm Hg.
Heart rate is 110 beats per minute.
Blood is noted in the oropharynx.
✓
Respiratory rate is 22 breaths per minute.
Correct Answer
Blood is noted in the oropharynx.
Blood in the oropharynx is an airway threat that requires priority intervention. Airway compromise takes precedence over breathing and circulation findings. The other vital sign findings, while abnormal, do not represent an immediate airway threat.
Question 10
Which finding indicates that a patient's respiratory compromise is improving?
Respiratory rate decreases from 28 to 20.
No extra effort is required to breathe.
✓
Oxygen saturation increases from 90% to 94%.
The patient can speak in two-word phrases.
Correct Answer
No extra effort is required to breathe.
When no extra effort is required to breathe, it indicates that the patient's respiratory compromise is improving. The absence of accessory muscle use, retractions, and labored breathing demonstrates improved respiratory function.
Question 11
What does the M in the SAMPLE mnemonic represent?
Medications
✓
Mechanism of injury
Mental status
Medical history
Correct Answer
Medications
In the SAMPLE mnemonic, M represents Medications. The full mnemonic is: Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the illness or injury.
Question 12
The question, "Do you have any reactions to medications?" helps gather history data for which part of the AMPLE mnemonic?
Allergies
✓
Past medical history
Last oral intake
Medications
Correct Answer
Allergies
Asking about reactions to medications helps gather information about the Allergies component of the AMPLE mnemonic. The AMPLE mnemonic stands for: Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the illness or injury.
Question 13
What is the AMPLE mnemonic used to assess?
Neurological status
Respiratory function
Pain level
Patient history
✓
Correct Answer
Patient history
The AMPLE mnemonic is used to assess patient history. It stands for Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the illness or injury. It provides a structured approach to gathering essential patient information.
Question 14
In an adult, which finding is an emergent threat?
Respiratory rate of 24 breaths per minute
Heart rate of 100 beats per minute
Blood pressure of 140/90 mm Hg
The patient cannot speak in complete sentences
✓
Correct Answer
The patient cannot speak in complete sentences
A patient who cannot speak in complete sentences has an emergent threat. Such a patient has compromised breathing effectiveness that requires immediate intervention. The other findings are abnormal but not immediately life-threatening.
Question 15
Which finding is evident during the circulation component of the primary assessment?
Unequal pupils
Sternal retractions
Audible stridor
Warm, dry skin
✓
Correct Answer
Warm, dry skin
Warm, dry skin is a finding assessed during the circulation component of the primary assessment. Skin color, temperature, and moisture provide important information about perfusion status. Stridor relates to airway, retractions relate to breathing, and unequal pupils relate to disability.
Question 16
A patient with which finding requires a focused neurologic assessment?
Dizziness
✓
Dyspnea
Hypotension
Tachycardia
Correct Answer
Dizziness
Any patient who presents with a neurologic complaint or deficit such as dizziness, headache, seizure, or altered mental status requires a focused neurologic assessment. Tachycardia, hypotension, and dyspnea are cardiovascular and respiratory findings.
Question 17
Which patients can usually maintain cardiac output by increasing the heart rate because the heart cannot increase contractility?
Obstetric
Geriatric
Bariatric
Pediatric
✓
Correct Answer
Pediatric
Pediatric patients maintain cardiac output primarily by increasing heart rate because the immature myocardium cannot significantly increase contractility or stroke volume. This is why tachycardia is often an early sign of distress in children.
Question 18
When evaluating a patient using the AVPU scale, a score of "P" indicates which response?
The patient is alert and oriented.
The patient responds to pain.
✓
The patient responds to verbal stimuli.
The patient is unresponsive.
Correct Answer
The patient responds to pain.
In the AVPU scale, P stands for Pain, meaning the patient responds only to painful stimuli. A stands for Alert, V stands for Verbal (responds to verbal stimuli), and U stands for Unresponsive.
Question 19
Which finding is likely to be the first sign that the patient's body is using compensatory mechanisms to maintain homeostasis?
The pulse rate increases.
✓
The skin becomes cool and clammy.
The blood pressure decreases.
The respiratory rate increases.
Correct Answer
The pulse rate increases.
An increase in pulse rate is often the first sign that the body is using compensatory mechanisms to maintain homeostasis. Tachycardia occurs early as the sympathetic nervous system responds to maintain cardiac output before other signs become evident.
Question 20
The FACES pain rating scale is designed for use in which age group?
Adolescents
Geriatric patients
Adults
Children age 3 and older
✓
Correct Answer
Children age 3 and older
The FACES pain rating scale (Wong-Baker) is designed for use in children age 3 and older. It uses a series of facial expressions ranging from smiling (no pain) to crying (worst pain) that children can point to in order to communicate their pain level.
Question 21
Which statement accurately characterizes abdominal assessment?
Bowel sounds should be assessed in all four quadrants for 1 minute each.
Palpation should always precede auscultation.
Pain caused by the sudden removal of the examiner's fingers suggests peritoneal irritation.
✓
Guarding indicates the patient is malingering.
Correct Answer
Pain caused by the sudden removal of the examiner's fingers suggests peritoneal irritation.
Rebound tenderness, which is pain caused by the sudden removal of the examiner's fingers from the abdomen, suggests peritoneal irritation. Auscultation should precede palpation. Guarding is a protective response, not malingering.
Question 22
Which disorder is a possible cause of a decreased level of consciousness?
Dehydration
Hypertension
Infection
✓
Anxiety
Correct Answer
Infection
Infection is a possible cause of a decreased level of consciousness. Sepsis and central nervous system infections can alter mental status. While dehydration can contribute to altered mental status, infection is the more direct cause of decreased consciousness among the options listed.
Question 23
Doppler ultrasonography can detect fetal heart tones beginning at about how many weeks' gestation?
16 weeks
6 weeks
20 weeks
10 weeks
✓
Correct Answer
10 weeks
Doppler ultrasonography can detect fetal heart tones beginning at approximately 10 weeks' gestation. A fetoscope can detect heart tones at approximately 20 weeks' gestation. Transvaginal ultrasound may detect cardiac activity as early as 6 weeks.
Question 24
Which technique is appropriate for neurovascular assessment of an extremity?
Splint the extremity to promote accurate initial assessment.
Evaluate pulse quality proximal to the injury site.
Assess capillary refill distal to the injury site.
✓
Assess for sensation at the joint above the injury site.
Correct Answer
Assess capillary refill distal to the injury site.
Assessing capillary refill distal to the injury site is the appropriate technique for neurovascular assessment. Neurovascular assessment evaluates circulation, sensation, and movement distal to the injury, not proximal.
Question 25
Which disorder could cause an inaccurate pulse oximetry reading?
Hypertension
Diabetes mellitus
Chronic obstructive pulmonary disease
Anemia
✓
Correct Answer
Anemia
Anemia can cause inaccurate pulse oximetry readings. Pulse oximetry measures the percentage of hemoglobin saturated with oxygen, but in anemia the total hemoglobin is reduced, so even with high saturation, the actual oxygen-carrying capacity may be inadequate.
Question 26
Which statement is the best example of a chief complaint?
Patient reports sudden onset of severe right lower abdominal pain.
✓
Rule out appendicitis.
Patient exhibits symptoms of possible food poisoning.
Skin is hot to the touch.
Correct Answer
Patient reports sudden onset of severe right lower abdominal pain.
A chief complaint should be a concise statement describing the patient's reason for seeking care in their own words. It should include onset, location, and severity. The other options are diagnoses, observations, or nursing assessments rather than chief complaints.
Question 27
Which patients are more prone to hypothermia due to ineffective temperature regulation?
Obstetric and bariatric
Pediatric and obstetric
Geriatric and pediatric
✓
Bariatric and geriatric
Correct Answer
Geriatric and pediatric
Geriatric and pediatric patients are more prone to hypothermia due to ineffective temperature regulation. Older adults have decreased metabolic rate and reduced subcutaneous tissue, while infants have a large body surface area relative to weight and immature thermoregulation.
Question 28
What is the pulse pressure?
An estimation of peripheral vascular resistance
The difference between the systolic and diastolic pressures
✓
A measurement of cardiac output
The quality and amplitude of the palpated pulse
Correct Answer
The difference between the systolic and diastolic pressures
The pulse pressure is the difference between the systolic and diastolic pressures. It represents the approximate stroke volume and is more sensitive than the systolic blood pressure to hypovolemic changes in early shock. Systolic pressure is a function of cardiac output. Diastolic pressure is a measure of peripheral vascular resistance.
Question 29
Which statement accurately characterizes pulse oximetry measurement?
It provides an accurate measurement during carbon monoxide exposure.
The two light sources should be positioned directly opposite the photo detector.
✓
Nail polish does not affect the reading.
It measures the partial pressure of oxygen in the blood.
Correct Answer
The two light sources should be positioned directly opposite the photo detector.
For accurate pulse oximetry measurement, the two light sources (red and infrared) should be positioned directly opposite the photo detector. Pulse oximetry measures oxygen saturation, not partial pressure. Nail polish can affect readings, and carbon monoxide causes falsely elevated readings.
Question 30
Which site for pulse assessment yields the most accurate information about the patient's condition?
Carotid
✓
Brachial
Radial
Femoral
Correct Answer
Carotid
The carotid pulse provides the most accurate information about the patient's condition because it is a central pulse that remains palpable even when peripheral pulses are diminished. It is closest to the heart and reflects cardiac function more accurately.
Question 31
Which action is a component of the primary survey?
Apply a warm blanket.
✓
Obtain a complete set of vital signs.
Obtain a 12-lead ECG.
Perform a head-to-toe assessment.
Correct Answer
Apply a warm blanket.
Applying a warm blanket is a component of the primary survey as part of the exposure/environment component. Preventing heat loss is essential during the primary assessment. Complete vital signs, head-to-toe assessment, and 12-lead ECG are components of the secondary assessment.
Question 32
During the primary assessment, which finding is most indicative of inadequate breathing?
Oxygen saturation of 97%
Clear breath sounds bilaterally
Asymmetric chest wall movement
✓
Respiratory rate of 18 breaths per minute
Correct Answer
Asymmetric chest wall movement
Asymmetric chest wall movement indicates inadequate breathing and suggests a possible pneumothorax, hemothorax, or flail chest. The other findings are within normal limits and do not indicate respiratory compromise.
Question 33
Which finding is likely during the inspection component of the respiratory assessment?
Use of accessory muscles
✓
Decreased tactile fremitus
Dullness to percussion
Crackles in the lung bases
Correct Answer
Use of accessory muscles
Use of accessory muscles is a finding identified during inspection (visual assessment) of the respiratory system. Crackles are found during auscultation, dullness during percussion, and decreased tactile fremitus during palpation.
Question 34
Bruising is noted on the right occiput. This finding was identified during which component of the assessment?
Primary assessment
Secondary assessment
✓
Ongoing assessment
Focused assessment
Correct Answer
Secondary assessment
Bruising on the right occiput is a finding identified during the secondary assessment, which includes the head-to-toe physical examination. The primary assessment focuses on life-threatening airway, breathing, circulation, and disability issues.
Question 35
Which intervention is appropriate during the exposure component of the primary assessment?
Insert a urinary catheter.
Obtain a complete set of vital signs.
Perform a rectal examination.
Remove clothing to identify injuries.
✓
Correct Answer
Remove clothing to identify injuries.
Removing clothing to identify injuries is appropriate during the exposure component of the primary assessment. The exposure component involves undressing the patient to identify all injuries while also preventing hypothermia. Rectal exams, complete vital signs, and catheter insertion are secondary assessment activities.
Question 36
Which Glasgow Coma Scale score indicates the patient is in a coma?
8
✓
15
3
12
Correct Answer
8
A Glasgow Coma Scale (GCS) score of 8 or less indicates the patient is in a coma. The GCS ranges from 3 (completely unresponsive) to 15 (fully alert and oriented). A score of 8 or below is the threshold for coma and typically indicates the need for airway protection.