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Answers to the Would You Pass the NCLEX? Part III

1. Situation– Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of hypertension, flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs. You are to measure the client’s initial blood pressure reading by doing all of the following EXCEPT:

• Take the blood pressure reading on both arms for comparison
  
• Listen to and identify the phases of Korotkoff’s sound
  
• Pump the cuff to around 50 mmHg above the point where the pulse is obliterated- Correct answer!
  
• Observe procedures for infection control
  

2. A pulse oximeter is attached to Mr. Dizon’s finger to:

• Determine if the client’s hemoglobin level is low and if he needs blood transfusion
  
• Check level of client’s tissue perfusion
  
• Measure the efficacy of the client’s anti-hypertensive medications
  
• Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops- Correct answer!

3. In which type of shock does the patient experiences a mismatch of blood flow to the cells?

• Distributive- Correct answer!
  
• Cardiogenic
  
• Hypovolemic
  
• Septic

4. The preferred route of administration of medication in the most acute care situations is which of the following routes?

• Intravenous- Correct answer!
  
• Epidural
  
• Subcutaneous
  
• Intramuscular

5. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

• inconsistent
  
• low systolic and high diastolic
  
• higher than what the reading should be- Correct answer!
  
• lower than what the reading should be

6. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should the nurse wait before taking the client’s blood pressure for accurate reading?

• 15 minutes
  
• 30 minutes- Correct answer!
  
• 1 hour
  
• 5 minutes

7. While the client has pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to:

• Set and turn on the alarm of the oximeter
  
• Do nothing since there is no identified problem
  
• Cover the fingertip sensor with a towel or bedsheet- Correct answer!
  
• Change the location of the sensor every four hours

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