Test 2 Vital signs, Communication and Documentation
A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with the diagnosis include:
easy wrinkling of the skin and sunken eyes
The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:
fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 inch above the crease of the elbow.
A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "that guy needs to get fired." The best response by the nurse would be to:
ask to speak to the physician in private and address any disrespectful remarks or behaviors.
A nurse is caring for a client who presents with a skin infection. While obtaining the patient's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should:
remain honest, open, and frank. One key factor to effective communication is to be open, accepting, frank, respectful, and without prejudice. When a client feels that a nurse is being judgmental, he or she might withhold significant information.
During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.5cm) in an adult and .5 inches (2.5cm) in an infant.
true
The nurse is assessing the blood pressure of a hospitalized patient using a Doppler ultrasound device. Which actions are performed correctly?
• The nurse checks that the needle on the aneroid gauge is within the zero mark. • The nurse wraps the cuff around the limb smoothly and snugly and fastens it. • The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. • The nurse places the patient in a comfortable lying or sitting position.
A nurse is assessing patients in the Emergency Department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods?
• When assessing an oral temperature with an electronic thermometer, place the probe beneath the patient's tongue in the posterior sublingual pocket. • When assessing rectal temperature with an electronic thermometer, lubricate about 1 inch of the probe with a water-soluble lubricant. • When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until you hear a beep.
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart."
A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?
"It is because of the immature ability to regulate temperature in general."
The nurse is assessing a patient's blood pressure and obtains a falsely low pressure reading. Which nursing actions might have contributed to this false reading?
-The nurse performed the assessment in noisy environment - The nurse misplaced the bell beyond the direct area of the artery. - The nurse failed to pump the cuff 20 to 30 mm HG above disappearing pulse
A nurse is assessing the respiratory rate of a sleeping infant. Which of the following would the nurse document as a normal finding?
30 to 60 breaths per minute
The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?
80/50 mm Hg and 145 bpm Explanation: Newborns and infants have higher heart rates and lower BP than adults.
The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?
80/50 mm Hg and 145 bpm newborns and infants have higher heart rates and lower BP than adults!!!
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has asked a nurse if he can read the documentation that his physician wrote in his chart.
Which patient would the nurse consider at risk for low blood pressure?
A patient with low blood volume
The nurse is preparing to measure a client's rectal temperature. Which of the following supplies and equipment should the nurse have available before beginning the procedure?
An electronic thermometer with a rectal probe • Disposable probe cover • Water-soluble lubricating gel
A female nurse states the following to another nurse who is constantly forgetting to wash her hands between patients: "It looks like you keep forgetting to wash your hands between patients. It's really not safe for your patients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech?
Assertive
A client has had a left-side mastectomy. How does this affect the blood pressure assessment?
Assessment is impeded! blood pressure monitoring on the same side can impede circulation, contributing to lypmhedema
A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a patient. Which signs and symptoms might occur related to this condition? (Select all that apply.) You selected:
Dizziness Lightheadedness Pallor
A client informs the nurse that she uses a mercury thermometer to take the temperature of her children when they are sick. What health education is most appropriate?
Encourage the client to use an alternative type of thermometer to assess temperature in the home.
A nurse takes a patient's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?
Graphic Sheets The graphic record is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.
Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?
Hemorrage ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure.
A nurse is transfusing multiple units of packed red blood cells (PRBCs). After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the patient reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which of the following statements represents the final step in this type of communication?
I think the client would benefit from intravenous furosemide (Lasix)."
It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. Which of the following is the characteristic of empathy?
Identifying with the client's feelings
A physician is in a hurry to leave the unit and tells the nurse to give a morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?
Inform the physician that a written order is needed. Explanation: Verbal orders should only be accepted during an emergency. No other action is correct other than asking the physician to write the order.
The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?
Interpersonal
A client monitoring his BP at home notices that his BP is higher in one arm than the other so he calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?
It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results. Correct
The nurse is communicating with a client who begins to cry. The nurse places her hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client?
Kinesthetic
The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds
When assessing an infants axillary temperature, it will be
One degree lower than ORAL temp
The nursing instructor is discussing communication with a student. The student identifies that a contract is made with the client during which phase of the nurse-client relationship?
Orientation phase
Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apicalradial pulse indicates that the two values differ significantly, a finding that suggests which of the following health problems?
Peripheral vascular disease
A nurse is assessing the blood pressure of an adult client using the korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document blood pressure in her client
Phase IV
Which of the following accurately reflects a recommended guideline when assessing blood pressure?
Raise the patient's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct.
The nursing is caring for a client who requests to see a copy of his or her medical records. What action by the nurse is most appropriate?
Review the hospital's process for allowing clients to view their medical records. The nurse needs to be aware of the policies regarding clients reviewing medical records. Teaching the client how to navigate the medical records is not appropriate. Hospitals can be fined for not allowing clients to view their medical records. There is no regulation requiring the clients to view a paper copy of the records.
Which guideline should a nurse use when choosing a position (location) in relation to a client during a verbal interaction?
Take note of the client cues when choosing a position and act on those cues.
When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?
Thready---
When collecting data on a client, the nurse implements which nonverbal communication form as one of the most effective to express feelings?
Touch Explanation: Touch, despite its individual variability, is viewed as one of the most effective nonverbal communication methods to express feelings. Not all cultures use direct eye contact; it may be considered disrespectful. Posture and gait are used to express feelings, but they are not as effective as touch
A nurse is caring for a client with orthostatic hypotension. Which of the following are symptoms of orthostatic hypotension?
Weakness • Syncope • Dizziness
