Evolve Module 2 post test 2

For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A) A patient without arms. B) A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). C) A patient with a history of a CVA (stroke). D) A patient who has an arteriovenous shunt located in the forearm for hemodialysis.

B

If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? A) 37° C to 39° C B) 96.8° F to 100.4° F C) 96.8° F to 98.6° F D) 35° C to 36° C

B

The student nurse is unsure of the BP measurement. What should the student nurse do first? A) Repeat the measurement on the same arm within 30 seconds. B) Measure the BP in the other arm. C) Get the RN to assess the BP. D) Determine whether the patient has had is or her BP medication.

B

Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, you should consider: A) Checking the carotid pulse. B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate. C) Counting the pulse again for 30 seconds and multiplying the results by two. D) Checking the radial pulse on the opposite side.

B

Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? A) An African-American patient with a systolic BP of 100. B) A football player with a diastolic BP of 94. C) An elderly patient with a systolic BP of 88. D) A pregnant woman with a diastolic BP of 67.

B

Why do you take BP in both arms on a "new" patient? A) To practice your technique. B) To ensure that you obtain an accurate BP reading. C) Because there is always a difference in dominant and nondominant hands, and it is good to know what that is. D) To assess for a pulse deficit.

B

What is the normal pulse range for an adult? A) 120 to 160 beats per minute. B) 90 to 140 beats per minute. C) 60 to 100 beats per minute. D) 50 to 80 beats per minute.

C

Identify the factors that may have an effect on an 82 year old patient's temperature.

-drinking a cold glass of water -participation of strenuous physical therapy exercises -infection -room temperature

You are validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? A) When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. B) When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. C) When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. D) After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.

A

Your newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? A) Temporal artery B) Tympanic C) Chemical dot D) Rectal electronic

A

The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? A) "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." B) "Since the soup was not hot, go ahead and take the patient's temperature." C) "Change to the red thermometer probe and take the patient's temperature rectally." D) "Take the patient's temperature using the axillary route and when you record the reading, add 1°F."

A The temperature of food or liquid could impair the accuracy of the reading. The nap should ask the patient not to eat, drink, or snack for 20 minutes and then assess the oral temperature. Taking rectal temp could be needlessly embarrassing and uncomfortable for the patient. Although the axillary rout could be used, it is less accurate than the oral rout. Furthermore, when recording an axillary temperature reading, the sire is documented, but the reading itself is unchanged.

Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) A) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. B) The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. C) The NAP waits until a tone sounds to read the tympanic thermometer. D) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. E) The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.

A B

Identify the factors that may have an effect on an 82-year-old patient's temperature: (Select all that apply.) A) Drinking a cold glass of water. B) Participation in strenuous physical therapy exercises. C) Infection. D) Room temperature. E) Patient's body weight.

A B C D

What should you do if you observe your patient taking more than 20 breaths per minute? (Select all that apply.) A) Count again for a full 60 seconds (1 minute). B) Tell the patient that you are counting breaths so the patient will slow the rate of breathing. C) Assess physiologic factors that may be causing the patient to breathe so fast. D) Administer a bronchodilator that will decrease the respiratory rate.

A C

Which of the following situations may affect a patient's vital signs? (Select all that apply.) A) Time of day. B) Occupation. C) Moving from lying to standing position. D) Pain rated as a 7 on 1-10 pain scale. E) Isolation precautions.

A C D Factors that may alter vial signs include time of day, stress (emotional and physical), temperature alterations/ weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumptions, and odors. The person's occupation and isolation precautions do not alter vital signs. if a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation.

Which of the following patients would require frequent assessment of their temperature? (Select all that apply) A) a patient receiving a blood transfusion for chronic anemia B) an elderly patient who needs assistance with feeding and dressing. C) An adult female in the recovery room following a hysterectomy D) A child who is below the normal height and weight for his age E) A young adult with a white blood cell count of 15,000/mm^3

A C E Certain conditions place patients

Which of the following may increase respiration rate and depth? (Select all that apply.) A) Walking 1 mile briskly. B) Having a pain level rating at 7 on a scale of 1-10. C) Feeling anxious when taking a test. D) Smoking a cigarette. E) Taking an opioid to relieve pain. F) Having an addiction problem with amphetamines/cocaine. G) Using a bronchodilator prior to exercise. H) Incurring a head injury from a motor vehicle accident.

A C F

You are taking a patient's vital signs. When you assess the respiratory rate, you are having difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is your best action? A) Have someone else assess the patient's respiratory rate. B) Remove the patient's gown so you have better visualization of the patient's chest for assessment. C) Document the inability to visualize inspiration and expiration. D) While holding the patient's wrist, move the patient's arm over the chest or abdomen, then feel the rise and fall of inspiration and expiration and assess the rate.

D

You should routinely auscultate the apical pulse with the bell side of the stethoscope. A) True. B) False.

B

Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A) Temp 96.8° F, P-60, R-18, BP 160/90, O2 sat 93%. B) Temp 97.0° F, P-60, R-16, BP 116/78, O2 sat 95%. C) Temp 98.6 °F, P-56, R-20, BP 120/80, O2 sat 91%. D) Temp 98.0 °F, P-76, R-22, BP 110/70, O2 sat 88%.

B Normal Values for an older adult are: average body temp Approx 36 C (96.8 F) HR: 60-100 BPM RRL 16-25 breaths per min average BP: Less than 120/80 Pulse ox: 95% -100% A BP greater than 140/90 may be an indication for hypertension

Who would you expect to have the lowest body temperature? A) A 16-year-old who ran 1 mile. B) An 80-year-old who walked half a mile. C) A toddler who is febrile. D) A child playing softball.

B The 80 year old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise. To be febrile means to have a fever. The toddler would fail to have the lowest body temp. A 16 y/o will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase it further.

The NAP Reports to the nurse a 65-year-old patient's blood pressure is 160/98. What is the appropriate initial response of the nurse? A) ask the NAP if the patient is nauseous B) Assess the patients blood pressure C) Instruct the NAP to obtain full set of vital signs D) Document this as a normal finding in an elderly adult.

B This is out of range. If there is a question regarding patient's vital signs or a suspected change in patient's condition that may require further assessment, the nurse should take the patient vital signs rather than delegating the task

n which of the following patients would you expect to find a decrease in pulse rate? (Select all that apply.) A) A newborn. B) A patient returning from OR after having a hip replacement. C) A patient who received morphine for severe cancer pain. D) A student who is getting ready to take a final exam. E) A patient who had a bleeding episode.

B C

You are supposed to take your patient's vital signs preoperatively and record them on the patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A) To see if the patient is "feeling funny." B) To provide a set of vital signs to use for comparison during and after surgery. C) To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. D) To provide the patient with reassurance that he or she is being cared for by a competent staff.

B C The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. If a patient reports feeling different, assessing vital signs is appropriate. There is no indication the patient is feeling different. Equipment should be maintained in a functional state at all times.

Which of the following patients would you suspect would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A) a 76-year-old with diabetes who is otherwise healthy. B) A patient who was just informed of a diagnosis of cancer. C) A patient with peripheral vascular disease. D) A patient who is receiving bolus IV fluids. E) A patient with Alzheimer's disease.

B C D

A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which information should be provided to the NAP delegated to take her temperature? (Select all that apply.) A) The patient's age. B) The type of temperature required. C) The patient's diagnosis. D) The frequency for taking or monitoring the temperature. E) What changes to report immediately to you, the physician, or their delegate.

B D E It is more important that the temperature be done on time by the correct rout, with the correct equipment, and the identified changes be reported as requested.

Which of the following would be appropriate to delegate the task of pulse assessment? (Select all that apply.) A) An apical pulse of a patient who is going to receive digoxin (Lanoxin). B) A radial pulse on a patient with a 1200 mL fluid restriction. C) A radial pulse of a patient in the emergency room with chest pain. D) A femoral pulse following a lower leg amputation. E) The temporal pulse of a child.

B E

How can you best obtain an accurate measurement of a patient's respiratory rate? A) Inform the patient that you are monitoring his or her respirations. B) Assess the respirations while the patient is talking. C) Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. D) Continue to act as though you are taking the patient's pulse while discretely observing the rise and fall of the patient's chest.

C

Which patient would it be appropriate for the nurse to delegate vital signs? A) New admission to the hospital B) Patient transferred from ICU C) Elderly nursing home resident D) Patient with Recent complaint of headache

C Nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could e reflective of hypertension, the nurse should assess the patient's vital signs.

Which of the following patients would require follow-up? A) A child with a respiratory rate of 24 breaths per minute. B) An adolescent with a respiratory rate of 16 breaths per minute. C) An adult with a respiratory rate of 10 breaths per minute. D) A newborn with a respiratory rate of 50 breaths per minute.

C Rational: The normal respiratory rate for a newborn is 30-60 breaths per minute. The normal respiratory rate of a child is 20 breaths per minute. The normal respiratory rate for a teenager is 16-20 breaths per minute. the normal respiratory rate for an adult is 12-20 BPM A rate of 10 would require a follow-up.

The NAP reports that the patient's temperature is 39° C. Which of the following are appropriate nursing actions? (Select all that apply.) A) Place the patient's feet in a tub of cool water with ice. B) Apply a hyperthermia blanket as ordered. C) Remove the patient's blankets. D) Limit the patient's fluid intake. E) Administer an antipyretic to the patient as ordered.

C E

For which patient would a tympanic thermometer be the preferred thermometer to use? A) A marathon runner who developed weakness during the race. B) A newborn in the intensive care unit who requires continuous temperature monitoring. C) A child who had tubes surgically placed in the ears. D) A tachypneic patient who is receiving oxygen by nasal cannula.

D An advantage to the tympanic thermometer is that it an be used for for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temp after exercise. A continuous measurement cannot be obtained with the tympanic thermometer.