ATI LPN Funsamentals Exam V

Extract:

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)

Question 1 of 5

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. check the patient's record to determine his baseline blood pressure.B. notify the charge nurse of the hypotension.C. check medications that might be the cause of the irregularity.D. notify the doctor of the bradycardia.

Correct Answer: A

Rationale: Checking baseline blood pressure (
A) verifies if 98/66 mm Hg is normal for the patient. Hypotension notification (
B) is premature, medications (
C) are secondary, and 76 beats/min isnâ€™t bradycardia (
D).

Extract:

Question 2 of 5

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A. pulse deficitB. diastolicC. auscultatory gapD. widened pulse pressure

Correct Answer: C

Rationale: An auscultatory gap (
C) is silence between Korotkoff sounds, indicating possible arterial stiffness. Pulse deficit (
A) compares pulses, diastolic (
B) is a pressure phase, and widened pulse pressure (
D) is the systolic-diastolic difference.

Extract:

Terminally ill patient with Cheyne-Stokes breathing

Question 3 of 5

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

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: C

Rationale: Cheyne-Stokes involves dyspnea then apnea (
C), common in terminal illness. Decreasing rate (
A), wheezing (
B), and shallow breaths (
D) donâ€™t match.

Extract:

Question 4 of 5

When educating a patient about the warning signs of cancer, the nurse includes which of the following? (Select all that apply.)

A. Persistent coughB. Difficulty in swallowingC. Changes in pulse rateD. Obvious change in a moleE. Vesicular breath soundsF. Hyperactive bowel sounds

Correct Answer: A,B,D

Rationale: Persistent cough (
A), swallowing difficulty (
B), and mole changes (
D) signal cancer. Pulse rate (
C), breath sounds (E), and bowel sounds (F) are unrelated.

Question 5 of 5

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

A. directly below the sternum.B. the left of the sternum at the third intercostal space.C. the left midclavicular line at the fifth intercostal spaceD. tightly above the left nipple.

Correct Answer: C

Rationale: The apical pulse is at the left midclavicular line, fifth intercostal space (
C). Sternum (
A), third space (
B), and nipple (
D) are incorrect.

ATI LPN Funsamentals Exam V | Nurselytic

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