PCA Basic Nursing Skills 2 — Questions and Answers
Question 1: When measuring a client's blood pressure, the cuff should be placed on the arm how many inches above the antecubital space?
- 1 inch (Correct answer)
- 3 inches
- 5 inches
- At the elbow crease
Correct answer: 1 inch
The blood pressure cuff should be placed approximately 1 inch (2-3 cm) above the antecubital space for accurate readings.
Question 2: A normal adult resting heart rate falls within which range?
- 40-60 beats per minute
- 60-100 beats per minute (Correct answer)
- 100-120 beats per minute
- 50-90 beats per minute
Correct answer: 60-100 beats per minute
A normal adult resting heart rate is 60-100 beats per minute; values outside this range should be reported.
Question 3: Which action is most important immediately AFTER removing soiled gloves during personal care?
- Apply hand lotion
- Wash hands with soap and water for at least 20 seconds (Correct answer)
- Put on a new pair of gloves
- Document the care provided
Correct answer: Wash hands with soap and water for at least 20 seconds
Handwashing with soap and water for at least 20 seconds after glove removal is essential to prevent cross-contamination.
Question 4: A client's temperature reads 101.2°F orally. Which action should the PCA take first?
- Give the client aspirin
- Apply a warm blanket
- Report the finding to the supervising nurse (Correct answer)
- Recheck temperature in 30 minutes without notifying anyone
Correct answer: Report the finding to the supervising nurse
A temperature of 101.2°F indicates fever and must be reported to the supervising nurse immediately for further assessment.
Question 5: Which site is considered the most accurate for measuring body temperature in adults?
- Axillary (armpit)
- Oral (mouth)
- Temporal (forehead)
- Rectal (Correct answer)
Correct answer: Rectal
The rectal route is considered the most accurate for measuring core body temperature in adults.
Question 6: When counting respirations, the PCA should count for how many seconds to get an accurate rate?
- 10 seconds then multiply by 6
- 15 seconds then multiply by 4
- 30 seconds then multiply by 2 (Correct answer)
- 60 seconds
Correct answer: 30 seconds then multiply by 2
Counting respirations for 30 seconds and multiplying by 2, or counting for a full 60 seconds, provides an accurate respiratory rate.
Question 7: A client's oxygen saturation reads 91% on a pulse oximeter. What should the PCA do?
- Continue routine care as this is normal
- Ask the client to breathe faster
- Report the reading to the nurse immediately (Correct answer)
- Remove the oximeter and recheck tomorrow
Correct answer: Report the reading to the nurse immediately
Normal SpO2 is 95-100%; a reading of 91% indicates low oxygen saturation and must be reported to the nurse at once.
PCA Basic Nursing Skills 2
When measuring a client's blood pressure, the cuff should be placed on the arm how many inches above the antecubital space?