foundations exam 2
A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
wait 30 min and return to measure the oral temp
what can pain tell us
warn of potential injury
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
temp
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn?
30-60
The nurse is taking the blood pressure on multiple clients. Which reading warrants the nurse to contact the doctor?
98/36
The NAP is taking vital signs and reports that a patient's BP is abnormally low. What should the nurse do next?
retake the BP personally and assess the patients condition
bradycardia
slow heart rate
bradypnea
slow respirations <10 breaths/min
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's BP?
smoking results in vasoconstriction, falsely elevating BP
how does lifestyle affect BP
sodium consumption, smoking, three or more alcoholic drinks per day
radiating pain
starts at the origin but extends to other locations
nonverbal communication
subconscious use of body language when sending a message
Its 6am and the UAP reports to the nurse that the patient has a temp of 96.7 tympanic which factor would explain this reading?
the patient is exhibiting a normal circadian rhythm
convection
the transfer of hear through air or water
A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition?
thermometer
how does a baby lose the most body heat
through their head
pain
unpleasant sensory/emotional experience
A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include:
use an electronic bed monitoring device
vital signs
variations in pulse, BP, and temp
what is subjective
what the patient says
objective
what you can see or touch
can a pt have pain in a body part that is not there anymore
yes; phantom pain
hyperventilation
rapid and deep breathing
hypoventialtion
rate and depth of respirations are decreased
if vital signs not in normal limits
recheck
variations in vital signs
reflect a persons state of health and/or functional ability of the body systems
Fire Safety: RACE
rescue alarm contain extinguish
The client is admitted with chest pain, which should be the nurse's priority assessment?
respiratory rate
what happens to BP in response to chronic pain
decreased systolic BP
risk factors of falls
-65 or older -reduced vision -orthostatic hypotension -lower extremity weakness -gait and balance problems
obtaining a temp
-Follow the measurement scale of the facility -Use the equipment approved by the facility -Choose the safest, most accurate, and more reliable site
assessing pain
-Obtaining a complete pain history -Nonverbal signs of pain - pain scales
evaporation
-Occurs when water is converted to vapor and lost from the skin -Evaporation is affected by the humidity
measuring BP
-Place stethoscope over an artery -Inflate the cuff; the artery is occluded as the pressure of the cuff exceeds the pressure in the artery -Deflate the cuff; blood begins to flow rapidly through the partially open artery, producing turbulent flow you will hear through the stethoscope
radiation
-The loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air -If the uncovered skin is warmer than the air, the body loses heat through the skin
counting the respiratory rate
-The nurse should count the respiratory rate (RR) after taking the radial pulse. -The patient can alter the rate and pattern of respirations. -RR must be accurate, especially in older adults.
obtaining a pulse rate
-Use a stethoscope to auscultate the number of heartbeats at the apex of the heart -A watch or clock with a second hand or digital display is required -A heartbeat is one series of the LUB and DUB sounds
non-pharm treatments
-heat and cold, -application and instruction -guided imagery -distraction
vital signs performed on regular basis
-hospital: every 4-8 hours -home health setting: each visit -clinic: each visit -SNF: weekly-monthly
when to measure apical pulse
-if radial weak or irregular -rate is less than 60 bpm or great than 100 bpm -patient taking cardiac meds -patient is infant or child up tp 3 y/o
chronic pain
-lasts 3-6 months or longer -often interferes with daily activities
acute pain
-short duration -rapid onset -varies in intensity, may last up to 6 months
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)
1) Place the client in a semi-fowler's position. Facilitates full ventilation and allows for a clear view of chest and abdominal movement 2) Have the client rest an arm across the abdomen. Its easier for the students to see respiratory movements. 3) Observing for one full minute cycle before starting to count assists the students in obtaining an accurate rate.
regular nursing assessment
ADPIE
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take first?
Ask the client if she is having pain. The first action the nurse takes using the nursing process is to assess for pain which can cause multiple complications, including elevated blood pressure. Therefore the nurse's first priority is to assess for pain. If the patient's blood pressure is still elevated after a pain assessment the nurse will notify the provider.
An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
BP
The unlicensed assistive personnel reports vital signs for a patient to the nurse. Temp 99.2F oral, pulse 88 and regular, resp 18 regular, BP 178/112, O2 sat of 96%, and 3/10 headache. What should the nurse be most concerned about?
BP
how does body position affect BP
BP is higher when a person is standing
how does disease affect BP
BP may be affected by certain diseases
how does diurnal variations affect BP
BP varies according to the persons daily schedule
Effect of hypoventilation
CO2 is retained
hypoventialtion associated with
COPD, general anesthesia, impending respiratory failure
hypertension
High BP 140/90
SBAR communication
Situation Background Assessment Recommendation
While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that:
a 3-year-old can safely sit in front seat of the car
A nurse is caring for a group of patients. Which patient will the nurse see first?
a calm adolescent with a P-95 and R-26
A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as:
a procedure-related incident
apnea
absence of breathing
primary hypertension
accounts fo 90% of cases no known cause
how does race affect BP
african americans have a higher rate of hypertension
cause of hyperventilation
anxiety, infection, shock, hypoxia, drugs
cutaneous/superficial
arises in the skin or the subcutaneous tissue
The nurse can best determine adequate arterial oxygen of the blood by assessing?
arterial oxygen level
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
assess the apical pulse for a full minute
how does gender affect BP
average BP for men is higher than women
psychogenic pain
believed to arise from the mind; patient perceives the pain despite there is no physical cause that can be identified
The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?
brachial
A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be:
braiding the hair to reduce tangles
The nurse is admitting a stable client for a minor outpatient procedure. What site would the most commonly use to assess the pulse rate?
radial
A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?
carotid
visceral pain
caused by stimulation of deep internal pain receptors; tight, pressure, or crampy pain
assertive communication
communication that takes a listener's feelings and rights into account
opioid med effect on vital signs
decreases breathing rate
pain can have
destructive effects
alternative to use of restraints
electronic devices and the posey bed
You are caring for a non-english speaking male patient. When preparing to assist him with personal hygiene you should:
ensure that culture and ethnicity influence hygiene practices
result of hyperventilation
excess loss of CO2
tachycardia
fast heart rate
tachypnea
fast respirations >24 breaths/min, usually shallow
how does stress affect BP
fear, worry, excitement, all cause a rise in BP
The nurse understands which statement is correct regarding respiratory rates?
healthy adults breathe between 12 and 20 times in a min
conduction
heat is transferred from a warm to a cool surface by direct contact
how does family history affect BP
history of hypertension - more likely an individual will get it
major cause of illness and death in US
hypertension
what part of brain regulates temp
hypothalamus
The client's blood pressure is being taken at a screening clinic. Which statement to the nurse demonstrates awareness of having a risk factor for hypertension?
i plan to get my blood pressure checked more often, as I am african american
referred pain
in an area that is distant from the original site
what happens to BP in response to acute pain
increased systolic BP and HR
how does obesity affect BP
increases BP
how does pain affect BP
increases BP
verbal communication
involves speaking or writing words to send a message
hypoxia
lack of oxygen
falls
leading cause of both fatal and nonfatal injuries among adults 65 and older
A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.
left side of the sternum to the fifth intercostal space, midclavicular line
hypotension
low BP less than 90/60
how do medications affect BP
many medications alter BP
apical pulse rate
most accurate
classifications of pain
origin cause duration description
deep somatic pain
originates in the ligaments, tendons, nerves, blood vessels, and bones; more localized and can be described as achey or tender
5th vital sign
pain
subjective
pain is subjective
communication should be
patient centered
phantom pain
perceived to originate from an area that has been surgically removed
how does exercise affect BP
physical activity reduces BP
role that clean dry and intact skin plays
protects from infection
The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data pair would support this evaluation?
pulse 114 BP 98/60