Foundations of Nursing Chapter 30 Vital Signs

3 Ovulation is associated with the release of greater amounts of progesterone into circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation.

A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for this? 1 Inhibin 2 Estrogen 3 Progesterone 4 Luteinizing hormone

3 Cleaning the sensor with an alcohol swab after taking a patient's temperature prevents transmission of microorganisms. Proper positioning of the thermometer sensors ensures accurate reading of the temperature. Returning the handled unit to the charging base protects the sensor tip from damage. Returning the thermometer to the charger or base maintains the battery charge of the thermometer unit.

After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. What is the rationale behind the nurse's action? 1 Ensuring accurate readings 2 Protecting the sensor tip from damage 3 Preventing transmission of microorganisms 4 Maintaining battery charge of thermometer unit

2 The acceptable range of heart rate in infants is between 120 and 160 beats per minute. When the heart rate of infants falls below 120 beats per minute, it is termed bradycardia. Tachycardia in infants occurs when the heart rate goes above 160 beats per minute. There are no terms such as primary tachycardia or tachycardia secondary to infection.

An infant with respiratory infection has a heart rate of 150 beats per minute. What term or phrase does the nurse use to record this finding in the case sheet? 1 Bradycardia 2 Heart rate within normal limits 3 Primary tachycardia 4 Tachycardia secondary to infection

2 The respiratory system begins to decline in healthy people after the age of 25. The respiratory system matures by the time a person reaches 20 years of age. Despite the decline in adults at 45 and 60 years of age, they can breathe effortlessly as long as they are healthy.

At which age does the respiratory system begin to decline in healthy people? 1 20 years 2 25 years 3 45 years 4 60 years

1 For adults, the nurse should pull the ear pinna backward, up, and out during temperature assessment at the tympanic membrane site. While assessing 3-year-old children, the covered probe is pointed toward the midpoint between the eyebrow and side burns. When assessing children older than 3 years of age, the nurse should pull the pinna up and back. When assessing children younger than 3 years of age, the covered probe is pointed toward the midpoint between the eyebrow and side burns.

For which patients should the nurse pull the ear pinna backward, up and out during temperature assessment at the tympanic membrane site? 1 Adults 2 3-year-old children 3 Children older than 3 years 4 Children younger than 3 years

2 The conditioning of athletes, especially runners, allows a resting rate below 60 beats/minute without interrupting the normal sinus rhythm of the heart. A heart rate below 60 beats/minute is considered bradycardia. Athletes often maintain heart rates consistent with sinus bradycardia because their heart is an effective pump with a greater-than-normal stroke volume. An obese person may experience an increase in resting heart rate secondary to cardiac demand. Bradycardia is not associated with diuretics or weight less than 90 lbs.

In which patient would a resting heart rate of 55 beats/minute be considered a normal finding? 1 An obese patient 2 An athlete 3 A patient who is taking a diuretic 4 A patient who weighs less than 90 lb

3 The definition of hypertension requires two elevated blood pressure measurements in a row (≥140 systolic pressure or ≥90 diastolic pressure). The other answers describe prehypertension.

The following blood pressures, taken 6 months apart, were from patients screened by the nurse at the assisted-living facility. Which patient should be referred to the healthcare provider for hypertension evaluation? 1 120/80, 118/78, 124/82 2 128/84, 124/86, 128/88 3 148/82, 148/78, 134/86 4 154/78, 118/76, 126/84

1, 3 The oral temperature for older adults may be inaccurate due to an inability to close the mouth completely, which may occur due to the absence of teeth and poor muscle control. The rigidity of the rib cage may cause chest wall expansion. The patient with downward-slanted ribs may have restricted chest expansion and decreased tidal volume. A patient with decreased sweat gland reactivity may suffer hyperthermia and heat stroke.

The nurse decides not to measure the temperature of an older adult using the oral site. What is the likely reason for this decision? Select all that apply. 1 Patient has no teeth 2 Patient has a rigid rib cage 3 Patient has poor muscle control 4 Patient's ribs are downward-slanted 5 Patient's sweat gland reactivity is decreased

1, 2, 5 Nail polish, artificial nails, and metal studs in the nails interfere with light transmission of the device and yield inaccurate results. The presence of hypothermia at the assessment site interferes with the device functioning properly because it decreases the peripheral blood flow. Dark skin pigmentation results in device malfunction and may yield an overestimation of saturation.

The nurse has been asked to measure the arterial oxygen saturation of a patient who has consumed an organic phosphorus poison. While using the pulse oximeter with digital probes, what are the factors that affect the functional ability of the device? Select all that apply. 1 Nail polish 2 Artificial nails 3 Hyperthermia 4 Fair skin pigment 5 Metal studs in nails

1 The patient should be positioned in the supine position to enhance circulation and restrict airway if the BP is decreased. The BP measurement should be repeated if the BP is above the acceptable range, and the findings should be compared. Antihypertensive medications should be administered as prescribed when the BP is above the acceptable range. When the BP reading cannot be obtained, the patient should be assessed for signs of decreased cardiac output.

The nurse is assessing a patient for blood pressure (BP) and identifies that the patient's BP is inadequate for perfusion and oxygenation of tissues. Which interventions should be provided immediately in this situation? 1 Repeat BP measurement in other arm. 2 Position the patient in supine position. 3 Administer antihypertensive medications. 4 Assess for signs of decreased cardiac output.

2 The evaluation step involves comparing a patient's current temperature reading with the patient's previous baseline and acceptable temperature range of his or her age group. This comparison reveals the presence of abnormalities. In the planning step, the nurse identifies the route by which the temperature reading should be taken, and the importance of maintaining proper position until the reading is complete. In the assessment step, the nurse assesses for signs and symptoms of temperature alterations and factors that accompany body temperature alterations. In the implementation step, the nurse obtains the temperature reading using an electronic thermometer.

The nurse is comparing the temperature reading with the patient's previous baseline temperature range. Which step of the nursing process is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

1 Intense body warmth and sweating in a menopausal woman indicate that she is having hot flashes. They occur due to instability of the vasomotor controls for vasodilation and vasoconstriction. They are due to vascular changes and not due to neurogenic changes. In menopause, there is a decreased estrogen level. Hot flashes are a symptom of menopause, and may not be due to fever.

The nurse notices intense body warmth and sweating lasting for up to 5 minutes in a 50-year-old woman. How does the nurse interpret these symptoms? 1 The nurse attributes them to menopause. 2 The nurse attributes them to neurogenic changes. 3 The nurse attributes them to increased estrogen. 4 The nurse attributes them to the presence of fever.

1, 2 A blood pressure of 166/110 mm Hg indicates that the patient is in stage 2 hypertension. Stage 2 hypertension is characterized by an average blood pressure reading of 160/100 mm Hg or above taken at two or more visits. The management of stage 2 hypertension includes referring the patient to the healthcare provider for diagnosis and prompt treatment, and then evaluating the patient within one month to assess the efficacy of treatment. For stage 1 hypertension, a confirmation is required within 2 months. Rechecking within 3 months or three different times in 6 months is not appropriate for stage 2 hypertension. The reevaluation should be done on a monthly basis.

The nurse records a blood pressure (BP) reading of 166/110 mm Hg in a patient. When she reviews his records, she sees that his previous recording was 159/112. What interventions are appropriate for this patient? Select all that apply. 1 Refer the patient to the healthcare provider. 2 Evaluate the patient again in 1 month. 3 Reassess the blood pressure within 2 months. 4 Recheck the blood pressure within 3 months. 5 Recheck the blood pressure three different times in 6 months.

3 A Doppler device is used to palpate the pulse of an older adult who is obese because it provides more accurate readings. An apnea monitor is a device used to measure respiratory rate. A pulse oximeter is used to measure oxygen saturation and the values obtained with this device are less accurate. The vinyl pressure cuff is used to measure blood pressure.

The registered nurse delegated the task of palpating the pulse of a 75-year-old obese patient to a licensed practical nurse (LPN). Which device used by the LPN would be appropriate to obtain more accurate readings in this patient? 1 Apnea monitor 2 Pulse oximeter 3 Doppler device 4 Vinyl pressure cuff

2 The nurse should demonstrate self-assessment of heart rate using the carotid pulse to patients, or an older caregiver but not to a young child. The nurse should teach the caregiver how to obtain blood pressure. The nurse should teach the patient about the importance of diet and exercise to promote health. The nurse should tell the patient about the risk factors for hypothermia, frostbite, and heat stroke to promote health.

The registered nurse is teaching a nursing student about teaching strategies for health promotion in patients. Which statement by the nursing student indicates a need for further learning? 1 "I should show the caregiver how to obtain blood pressure." 2 "I should demonstrate assessment of carotid pulse to a young child." 3 "I should teach the patient about the importance of diet and exercise." 4 "I should tell the patient about risk factors for hypothermia and frostbite."

2, 5, 4, 6, 3, 1 To measure temporal artery temperature with an electronic infrared thermometer, the nurse should first ensure that the forehead is dry and wipe it with a towel if needed. Next, the sensor flush should be placed on patient's forehead above the eyebrow. Then, the red scan button should be pressed with the thumb, and the thermometer should be slowly slid across the forehead. The sensor should be lifted keeping the scan button on and the sensor should be touched to the skin on the neck. A clicking sound is heard when the peak temperature is recorded; then the scan button should be released. The sensor should be cleaned with an alcohol swab, and finally the thermometer should be returned to the charger or thermometer base.

What is the correct order of steps for measuring temporal artery temperature? 1. Return the thermometer to the charger. 2. Ensure that the forehead is dry. 3. Clean the sensor with an alcohol swab. 4. Press the red scan button with your thumb. 5. Place the sensor flush on the patient's forehead. 6. Lift the sensor from the forehead and touch the sensor to the skin on the neck.

4 For a patient with stage 1 hypertension, the recommendation for blood pressure follow-up would be 1 month. For a patient with stage 2 hypertension, the recommendation for blood pressure follow-up would be within 1 month. Prehypertension patients require recheck in 1 year. Patients with normal blood pressure would require recheck in 2 years.

What would be the follow-up recommendation suggested by the primary health care provider to a patient with stage 1 hypertension? 1 1 year 2 2 years 3 1 week 4 1 month

2 The respiratory system matures by the age of 20 years in healthy people. At the age of 25, the respiratory system starts to decline. At the ages of 35 and 50 years, people can breathe effortlessly as long as they are healthy.

When does the respiratory system mature in healthy people? 1 25 years 2 20 years 3 35 years 4 50 years

2, 3, 4 To ensure proper positioning of the probe against the blood vessels in the axilla, the probe should be placed into the center of the axilla. The arm should be lowered over the probe and placed across the chest. This helps in proper positioning of the probe. Raising the arm away from the torso only helps in inspecting local conditions and does not ensure proper positioning of the probe. The probe should not be placed against the lateral wall. It should be placed into the center of the axilla.

When measuring the axillary temperature of a patient, how can the nurse ensure proper positioning of the probe against the blood vessels in the axilla? Select all that apply. 1 By raising the arm away from the torso 2 By placing the probe into the center of the axilla 3 By lowering the arm over the probe 4 By placing the arm across the chest 5 By placing the probe against the lateral wall of the axilla

3, 4, 5 Opioid analgesics, sedative hypnotics, and general anesthetics depress respiratory rate and depth. Cocaine and amphetamines would increase respiratory rate and depth.

Which drugs does the nurse expect to depress respiratory rate and depth? Select all that apply. 1 Cocaine 2 Amphetamines 3 Opioid analgesics 4 Sedative hypnotics 5 General anesthetics

1 Pain, a subjective symptom, is often called the fifth vital sign because it is an indicator of health status and, therefore, it is frequently measured with other vital signs. Pulse, temperature, blood pressure, and respiration are the main vital signs because they indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions.

Which manifestation is often called the fifth vital sign? 1 Pain 2 Pulse 3 Temperature 4 Blood pressure

4 The temporal site, which is present over the temporal bone of the head, above and lateral to the eye, should be assessed in children to determine pulse. The apical site is used to auscultate for the apical pulse. The carotid site can be accessible during physiological shock or cardiac arrest when other sites are not palpable. The brachial site is used to assess the status of circulation to the lower arm and to auscultate blood pressure.

Which site should be used by the nurse to determine pulse in children? 1 Apical 2 Carotid 3 Brachial 4 Temporal

2 Radiation is a heat loss mechanism of the body. If the environment is warmer compared to the skin, the body absorbs heat through radiation without any direct contact. Peripheral vasodilation increases the blood flow from the internal organs to the skin to increase radiant heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between them. Radiation increases as the temperature difference between the objects increases.

Which statement is true regarding the radiation heat loss mechanism of the body? 1 Peripheral vasodilation minimizes radiant heat loss. 2 Radiation is the transfer of heat from one object to another without direct contact. 3 Radiation increases as the temperature difference between the objects decreases. 4 The body absorbs heat through radiation if the environment is warmer than the skin.

2, 3, 5 The NAP can determine the frequency of respiration, measure oxygen saturation, and obtain pulse measurement frequency at appropriate times if the condition of the patient is stable. The skill of palpating blood pressure cannot be delegated to the NAP. A patient with an irregular pulse may be in critical condition, so this task is not delegated to the NAP. The skill of orthostatic hypotension requires critical thinking and ongoing nursing judgment when determining a patient's response to repositioning, so this task is not delegated to the NAP.

Which task can be delegated to nursing assistive personnel (NAP)? Select all that apply. 1 Palpating systolic blood pressure 2 Obtaining frequency of respiration 3 Measuring the oxygen saturation 4 Measuring orthostatic hypotension in different positions 5 Obtaining pulse measurement frequency at appropriate times

1 As radial and apical locations are most common sites for pulse rate measurement, if the radial pulse is abnormal or intermittent due to dysrhythmias, or if it is inaccessible because of a dressing or cast, the patient's apical pulse should be assessed. The carotid site is recommended for quickly finding and assessing the pulse when other sites are not palpable. Therefore, carotid pulse is not the most appropriate option if the radial pulse is abnormal or intermittent. The brachial pulse is the best site for assessing the pulse of an infant or young child. However, obtaining brachial pulse is unnecessary when routinely obtaining the vital signs. The temporal site is an easily accessible site, which is used to assess pulse in children. However, the apical site is more commonly used.

While assessing a patient, the nurse finds that the radial pulse is abnormal. Which pulse should the nurse assess next in this situation? 1 Apical 2 Carotid 3 Brachial 4 Temporal

3 While measuring a patient's axillary temperature, the nurse should inspect the skin for lesions and excessive perspiration, as lesions may alter the local skin temperature. The thermometer probe should be held in place until the audible signal is heard to ensure accurate readings. The arm is not raised to provide comfort to the patient while measuring the axillary temperature. Raising the arm away from the torso would not prevent the transmission of microorganisms.

While assessing the axillary temperature, the nurse raises the patient's arm away from the torso. What is the rationale behind this action? 1 Ensuring accurate readings 2 Providing comfort to the patient 3 Inspecting for the presence of lesions 4 Preventing the transmission of microorganisms

1, 2, 3 When the temperature has dropped 1 degree below the normal range after treatment, the nurse should immediately eliminate any drafts, provide extra blankets for warmth, and monitor the apical pulse rate. The nurse should assess for localized infections when the temperature of the patient 1 degree above the normal range. The nurse should notify the healthcare provider if there are persistent wide fluctuations in temperature.

While assessing the body temperature of a patient after treatment, the nurse observes that the temperature has dropped 1 degree below the normal range. Which interventions should the nurse follow in this situation? Select all that apply. 1 Eliminate drafts. 2 Provide extra blankets. 3 Monitor apical pulse rate. 4 Assess for localized infections. 5 Notify the healthcare provider

4 Closing the lips after placing the thermometer into the mouth helps maintain the proper position of the thermometer. Accurate measurement depends on correct positioning of the thermometer under the tongue in the sublingual pockets. Instructing the patient to close the lips is not to provide comfort, nor does it reduce the transmission of organisms.

While assessing the oral temperature of a patient using an electronic thermometer, the nurse asks the patient to close his or her lips. What is the rationale behind this instruction? 1 Ensures proper measurement 2 Provides comfort to the patient 3 Reduces transmission of organisms 4 Maintains proper position of the probe

2 Intermittent fever is characterized by spikes in temperature coupled with periods of normal temperature that occur at least once every 24 hours. In a sustained fever, the fever is continuous. In a remittent pattern, the fever spikes and falls without a return to normal temperature. In a relapsing fever, the fever lasts for more than 24 hours then alternates with a nonfebrile stage of 24 hours or more.

A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What pattern of fever does the child have? 1 Sustained 2 Intermittent 3 Remittent 4 Relapsing

4 Oxygen therapy increases oxygen saturation. Temperature is not affected by the oxygen. There is no change in heart rate. Administering oxygen should decrease the respiratory rate. The decline in blood pressure is unlikely to be caused by oxygen.

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost more than 10 pounds. Her vital signs on admission are: heart rate (HR) 112, blood pressure (BP) 138/82, respiratory rate (RR) 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1 Temperature: 37° C (98.6° F) 2 Radial pulse: 112 3 Respiratory rate: 24 4 Oxygen saturation: 96% 5 Blood pressure: 134/78

1, 2, 4, 7 To plan interventions for this patient's infection the nurse would need to know the patient's heart rate, presence of diaphoresis, respiratory rate, and the patient's normal temperature. The patient's bowel movement and blood pressure are not data that are integral to planning this patient's care.

A 56-year-old patient with diabetes admitted for community-acquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? Select all that apply. 1 Heart rate 2 Presence of diaphoresis 3 Smoking history 4 Respiratory rate 5 Recent bowel movement 6 Blood pressure in right arm 7 Patient's normal temperature 8 Blood pressure in distal extremity

2, 3, 5 The nurse should know the patient's medical history to know which vital signs would be affected by medications, environmental factors, or the ability to detect complications. Proper equipment per the age of the patient should be used to prevent errors. The vital signs should be used as an indicator for administration of medication. For example, certain cardiac drugs would be used only within a range of pulse of blood pressure values. The frequency of measuring the vital signs has to be discussed with the primary health care provider. It is not necessary to immediately report changes in the vital signs to the healthcare provider unless the change is significant.

A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply. 1 Measure the vital signs four times per day. 2 Determine the patient's medical history. 3 Use equipment that is appropriate per the age of the patient. 4 Report all changes in vital signs to the health care provider. 5 Use vital sign measurements to determine indications for medication administration.

2, 3, 5 Core and surface body temperature can be measured at several sites. Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. These measurements require the use of continuous invasive devices placed in body cavities or organs and continually display readings on an electronic monitor. Intermittent temperature measurements are obtained from the mouth, rectum, tympanic membrane, temporal artery, and axilla. The ulnar artery and dorsalis pedis artery are usually not employed for measuring the body temperature in a patient. These arteries are palpated to check for the pulse.

A healthcare provider instructs the nurse to measure the body temperature of a patient. Which sites does the nurse choose to measure body temperature? Select all that apply. 1 Ulnar artery 2 Temporal artery 3 Pulmonary artery 4 Dorsalis pedis artery 5 Tympanic membrane

3 Aneroid sphygmomanometers require biomedical calibration once every 6 months to verify their accuracy. A year is too long a period between calibrations. A bimonthly calibration or a calibration every month is more frequent than needed for calibrations.

A hospital uses aneroid sphygmomanometers for measurement of blood pressure. How does the nurse ensure the instrument's accuracy? 1 Annual biomedical calibration 2 Bimonthly biomedical calibration 3 Biomedical calibration every 6 months 4 Biomedical calibration on a monthly basis

2, 3, 4 The electronic sphygmomanometer requires frequent recalibration, at least more than once in a year, to ensure accuracy. These devices do not require the use of a stethoscope because they are electronic. The device is very sensitive to the movement of the arm, and may give a false reading. Electronic sphygmomanometers are simple and easy to operate. They may give false readings if the cuff is not placed properly.

A hypertensive patient expresses that he is too busy to go to a clinic to have his blood pressure taken. The patient wishes to monitor his blood pressure on his own. What should the nurse educate this patient about the electronic sphygmomanometer? Select all that apply. 1 It is difficult to manipulate. 2 It requires frequent recalibration. 3 It does not require the use of a stethoscope. 4 It may give an incorrect reading with movement of the arm. 5 It does not give a false reading with improper cuff placement.

37 To convert Fahrenheit to Celsius, the Fahrenheit reading should be subtracted by 32, and then the result should be multiplied by 5/9. Applying this formula to 99° F, we get (99 - 32) × 5/9 = 37. Or (99 - 32) / 1.8 = 37

A patient has a body temperature of 99° F. What temperature does the nurse record in Celsius? Record your answer using a whole number. ___° C

1, 3, 4 The recommendations for a patient with a family history of hypertension include discouraging smoking and heavy drinking. Smoking and heavy drinking promote atherosclerosis. A sedentary lifestyle increases the risk of hypertension; discouraging a sedentary lifestyle helps to reduce obesity and the risk of hypertension. A certain amount of salt is required for physiological function, so only a high-sodium diet should be discouraged. The patient is genetically predisposed to having hypertension in the future, but the patient does not have hypertension now. Lifestyle and diet modifications may be sufficient to prevent the occurrence of hypertension in this patient; the patient need not use antihypertensives for prophylaxis.

A patient has a family history of hypertension. What education is helpful in reducing the risk of hypertension in the patient? Select all that apply. 1 Discouraging smoking 2 Encouraging a diet completely without salt 3 Discouraging heavy alcohol intake 4 Discouraging a sedentary lifestyle 5 Starting prophylactic antihypertensive medication

4800 Cardiac output is the product of heart rate and stroke volume. Hence, the cardiac output in the patient is 80 × 60 = 4800 mL.

A patient has a heart rate of 80 beats per minute and a stroke volume of 60 mL per beat. What is the cardiac output that the nurse records for the patient? Record your answer using a whole number, and please note, no comma is needed. ___ mL

3 Biot's respiration is the presence of abnormally shallow breaths followed by irregular periods of apnea. The cessation of respiration for several seconds is called apnea. Bradypnea is a regular, slow respiration of less than 12 breaths per minute. Kussmaul's respiration is an abnormally deep, regular, and increased rate of respiration.

A patient has abnormally shallow respirations followed by irregular periods of apnea. What term does the nurse use to record this breathing pattern? 1 Apnea 2 Bradypnea 3 Biot's respiration 4 Kussmaul's respiration

1, 2, 4 The temperature control mechanism of newborn babies is immature, and babies respond drastically to environmental temperatures. Hence, babies should be adequately clothed, and the head of the baby should be covered by a cap to prevent heat loss. Newborn babies should not be exposed to extreme temperatures; extreme temperatures can harm them. The body temperature should be kept between 95.9° F (35.5° C) and 99.5° F (37.5 ° C), because this is the normal range of body temperature for newborns; temperatures above 99.5° F (37.5 ° C) indicate fever.

A patient has delivered a baby at full term. What does the nurse teach the patient about protecting newborns from environmental temperature? Select all that apply. 1 Teach the importance of adequate clothing. 2 Emphasize covering the head of the baby with a cap. 3 Explain that extra care is not required for full-term babies. 4 Instruct the patient to avoid exposing infants to extreme temperatures. 5 Encourage the patient to keep the baby's body temperature above 99.5° F (37.5° C).

3 Corticosteroids reduce heat production by interfering with the immune system. As a result, they bring down the temperature of the patient. Salicylates, indomethacin, and acetaminophen reduce the body temperature by promoting heat loss from the body.

A patient is admitted to the hospital with high fever. The healthcare provider tells the nurse to administer a drug to decrease heat production in the patient. Which drug will most likely be prescribed to this patient? 1 Salicylates 2 Indomethacin 3 Corticosteroids 4 Acetaminophen

3, 4, 5 Benazepril is an angiotensin-converting enzyme (ACE) inhibitor. It lowers blood pressure by lowering the circulating blood volume, by producing vasodilation of blood vessels, and by reducing aldosterone production and water retention. Beta-adrenergic blockers, not benazepril, act by reducing the heart rate and cardiac output.

A patient on benazepril for hypertension asks the nurse about how the medication works. Which statements are appropriate responses by the nurse? Select all that apply. 1 "It reduces the heart rate." 2 "It reduces cardiac output." 3 "It lowers the circulating blood volume." 4 "It produces vasodilation in the blood vessels." 5 "It reduces aldosterone production and water retention."

3 Your priority is to assess the patient first. The nurse cannot delegate vital signs for an unstable patient. Therefore, first you determine if the patient has a pulse deficit. Calling for an ECG and administering cardiac-stimulating medications are interventions that require notification of the healthcare provider and occur after you assess the patient.

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention? 1 Request that the nursing assistant repeat the pulse check. 2 Call for a stat electrocardiogram (ECG). 3 Assess the patient's apical pulse and evidence of a pulse deficit. 4 Prepare to administer cardiac-stimulating medications.

1, 2, 4 A fan promotes the loss of heat through convection. Heat loss through conduction can be encouraged by the application of ice packs and bathing the patient with a cool cloth. Aquathermia pads help the body gain heat through conduction; they do not promote heat loss. Covering the body with dark and closely woven clothes reduces heat lost from radiation; the clothes will not decrease the patient's body temperature.

A patient presents to an emergency room with a high body temperature. Which nursing measures does the nurse implement to reduce the patient's body temperature? Select all that apply. 1 Switch on a fan. 2 Apply an ice pack. 3 Apply an aquathermia pad. 4 Bathe the patient with a cool cloth. 5 Cover the body with dark and closely woven clothes.

1, 2, 4 In a normal circadian rhythm, the normal body temperature is highest at around 4:00 pm and lowest between 1:00 am and 4:00 am. The temperature change during a 24-hour period is usually between 0.5° C and 1° C. The circadian temperature rhythm does not alter with age. In night-shift workers, the temperature pattern does not change automatically within one week of beginning the night shift. It takes up to 3 weeks for such a change to happen.

A patient reports to the nurse increased body temperature in the evening and decreased body temperature in the morning. What does the nurse educate this patient about normal circadian rhythms? Select all that apply. 1 "The highest body temperature occurs at around 4:00 pm." 2 "The lowest body temperature occurs between 1:00 am and 4:00 am." 3 "There will be alterations in circadian rhythm due to age." 4 "A normal body temperature change in a 24-hour period is 0.5° C and 1° C." 5 "Temperature patterns automatically reverse within one week of beginning to work a night shift."

1, 3, 5 The posterior hypothalamus senses if the body temperature drops below the set point, at which point the body then initiates heat-conservation mechanisms. Shivering is the mechanism that occurs when vasoconstriction is ineffective in preventing heat loss. Vasoconstriction, or narrowing of blood vessels, is a heat-conservation mechanism that reduces blood flow to the skin and extremities. Voluntary muscle contraction is a compensatory heat production mechanism. Excessive sweating and vasodilation are the heat loss mechanisms that are controlled by the anterior hypothalamus.

A registered nurse is asking the nursing student to list the mechanisms that would occur in a patient when the posterior hypothalamus senses that the body temperature is lower than the set point. Which mechanisms listed by the student indicate effective learning? Select all that apply. 1 Muscle shivering 2 Excessive sweating 3 Narrowing of blood vessels 4 Inhibition of heat production 5 Voluntary muscle contraction

2, 4, 5 Elderly people have poor vasomotor control. There is inefficient vasomotor regulation in response to alterations in temperature. Fat and subcutaneous tissues play a major role in insulation. There is reduction of subcutaneous tissue in aging. The activity of the hypothalamus and thus the temperature control mechanism also deteriorates with aging. Metabolism and sweat gland activity decrease with aging, making the temperature control mechanism less effective.

An elderly patient has recently shifted to a residence located at a high altitude and finds it difficult to cope with extreme temperatures. The patient feels that there is a body system problem because the patient experiences more cold than other people do. The nurse explains to the patient that this is a normal response to aging. What is the rationale for this response? Select all that apply. 1 "Aging increases metabolism." 2 "Aging causes poor vasomotor control." 3 "Aging increases sweat gland activity." 4 "Aging reduces subcutaneous tissue." 5 "Aging affects the temperature control mechanism."

2 The carotid artery is the most suitable site for assessing the patient's pulse, because it can be located quickly and provides a good reading on the pulse, as the heart delivers blood through the carotid artery. The ulnar site is used for assessing the status of circulation to the hands. The popliteal site is used to assess the status of circulation to the lower leg. The temporal site is used to assess pulse in pediatric patients.

An older adult patient was brought to the hospital after a cardiac arrest, and is being treated and kept under observation. The nurse finds that the patient's condition is suddenly worsening. Which site should the nurse immediately assess to obtain the patient's pulse? 1 Ulnar site 2 Carotid site 3 Popliteal site 4 Temporal site

3 The priority intervention for patients with hypothermia is to prevent a further decrease in body temperature. Therefore, the first intervention is to remove the patient's wet clothes and replace them with dry ones. Hot drinks can be offered to the patient after attaining some stability. The patient can be placed in a warm room after changing the wet clothes. The patient should lie under blankets to provide additional warmth to the body after replacing the wet clothes.

Which priority nursing intervention should be implemented for a patient with hypothermia? 1 Providing hot drinks to the patient 2 Placing the patient in a warm room 3 Removing the patient's wet clothes 4 Having the patient lie under blankets

1 The ventilatory rhythm in a patient can be determined by observing the chest or the abdomen. Diaphragmatic breathing results from the contraction and relaxation of the diaphragm. Ventilatory depth can be determined by assessing the depth of respirations by observing the degree of excursion or movement in the chest wall. The respiratory rate can be determined by observing a full expiration and inspiration when counting ventilation or respiration rate.

How should the nurse determine the ventilatory rhythm in a patient? 1 Observing the chest or the abdomen 2 Observing the degree of excursion in the chest wall 3 Observing full expiration when counting ventilation 4 Observing full inspiration when counting ventilation

1, 3, 3, 5 Dietary habits may include caffeinated fluids and foods that stimulate the heart rate. The medication list may include pharmacological agents that increase or decrease heart rate such as positive chronotropic drugs such as epinephrine. If the patient's heart had been conditioned by long-term exercise, the heart rate would normally be slower. On the other hand, short-term exercise can increase pulse rate. Activities that reduce stress would normally slow a patient's heart rate. Sympathetic stimulation can increase heart rate. Knowing that the patient participates in activities that reduce stress might eliminate one factor that potentially could cause a racing heart. The patient's age, weight, and height would not directly cause a patient's heart to "race."

During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's "racing," usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating the patient's racing heart? Select all that apply. 1 Dietary habits 2 Medication list 3 Exercise regimen 4 Age, weight, and height 5 Patient's participation in activities that reduce stress

1 Assessment of pertinent laboratory values, including serum potassium can help determine the reason for increased pulse rate, as the elevated or decreased potassium levels may cause dysrhythmias. Complete blood count helps to determine low hemoglobin values, which is the reason for reduced oxygen transport. Assessing a patient for the presence of edema in the extremities can determine if there is local obstruction to one extremity which would decrease peripheral blood flow. Assessing a patient for symptoms of peripheral vascular disease can determine the reason for alterations in local arterial blood flow.

During the assessment of a patient's radial and apical pulses, the nurse also checks the most recent serum potassium result. What is the reason for this assessment by the nurse? 1 To determine the reason for increased pulse rate 2 To determine the reason for reduced oxygen transport 3 To determine the reason for the presence of edema in the extremities 4 To determine the reason for alteration in local arterial blood flow

2 The sounds auscultated during BP measurement can be differentiated into five phases. The whooshing or blowing sound is observed by the nurse in phase 2. A sharp thumping sound is observed in phase 1. A crisp, intensive tapping sound is observed in phase 3. A softer blowing sound that fades is observed in phase 4.

In which phase does the nurse observe blowing and whooshing sounds during blood pressure (BP) measurement? 1 Phase 1 2 Phase 2 3 Phase 3 4 Phase 4

1, 3, 4 The body maintains a balance between heat production and heat loss. This is reflected by various temperature readings throughout the day. Exercise such as long-distance running, stress, and strong emotions can increase cellular activity, thus raising body temperature. Body temperature may increase as high as 1 degree Fahrenheit because of an increase in physical activity throughout the day and is at its peak at 4.00 pm; thereafter it decreases. Taking a stroll in the park does not raise body temperature because it does not cause physical exertion. For most people, body temperature is usually lowest in the morning because of a decrease in the basal metabolic rate related to inactivity during the night.

On examination, the nurse finds that the patient's body temperature is high. What are the situations when the body temperature rises above the baseline? Select all that apply. 1 After long-distance running 2 After taking a stroll in the park 3 During physical or emotional stress 4 During the evening, maximum at 4:00 pm 5 During early morning from 1:00 am to 4:00 am

60 Pulse pressure is the difference between systolic and diastolic blood pressure. Therefore, 150 - 90 mm Hg = 60 mm Hg, which is the pulse pressure in the patient.

The blood pressure of an older patient is 150/90 mm Hg. What could be the pulse pressure in this patient? Record the answer using a whole number. _______ mm Hg

1 The patient with a low pulse oximetry reading and elevated respiratory rate should be assessed first. Oxygen saturation is low (< 90%), indicating a problem with ventilation or diffusion, which is related to the respiratory rate. A respiratory rate above 27/minute is an important risk factor for cardiac arrest. The other patients are more stable with no critical vital sign values.

The licensed practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? 1 An 84-year-old man recently admitted with pneumonia, respiratory rate 28, SpO2 89% 2 A 54-year-old woman admitted after surgery for fractured arm, blood pressure 160/86 mm Hg, heart rate 72 3 A 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), heart rate 84 4 A 77-year-old woman with left mastectomy 2 days ago, respiratory rate 22, blood pressure 148/62

2, 4 Patients with hypertension may have an auscultatory gap where the sound disappears between the first and second Korotkoff sound. Therefore, when measuring the blood pressure, the nurse should listen to the Korotkoff sound until the cuff is deflated. Making sure that the bell of the stethoscope is placed firmly over the artery helps to hear the Korotkoff sound clearly. Stopping midway and beginning to inflate again may give a false reading. Pumping up the cuff until no sound is heard and then releasing the air is a part of regular blood pressure measurement. The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap.

The nurse finds that a patient with hypertension has an auscultatory gap. What should the nurse do when taking the patient's blood pressure measurement? Select all that apply. 1 Stop midway and begin to inflate again. 2 Continue to listen until the cuff is deflated. 3 Pump up the cuff until no sound is heard, then let the air out. 4 Make sure the bell of the stethoscope is placed firmly over the artery. 5 Inflate the cuff just enough to hear the systolic pressure.

1, 2, 3 Respiratory efficiency is assessed by collecting data from diffusion (movement of oxygen and carbon dioxide between alveoli and red blood cells), perfusion (distribution of red blood cells to and from the pulmonary capillaries), and ventilation (movement of gases in and out of the lungs). Spinal reflexes are not involved in controlling respiration. Respiratory muscle strength is one of the factors determining ventilation. Data related to respiratory muscle strength would not directly reflect the respiratory efficiency.

The nurse has been asked to measure the respiratory efficiency of a patient. What data are collected to reflect the processes involved in assessing respiratory efficiency? Select all that apply. 1 Diffusion 2 Perfusion 3 Ventilation 4 Spinal reflexes 5 Respiratory muscle strength

1 The radial site is commonly used for assessing the nature of the pulse and is also used for assessing circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The brachial site is suitable for assessing circulation in the upper limb and auscultating blood pressure. The temporal site is easily accessible and is suitable for assessing the pulse in children.

The nurse has been asked to record the nature of the pulse in a patient. What peripheral pulse is the most common and easiest to assess for pulse rate assessment? 1 Radial 2 Carotid 3 Brachial 4 Temporal

4, 5 Various sites can be used to measure temperature in infants. In this case, the infant could be HIV positive so it is important to use sites where there is a low risk of exposure to body fluids for the nurse. There is a risk of exposure to body fluids in both oral and rectal sites, so these are not appropriate in this case. The tympanic membrane site can be used in this case because there is low risk of exposure to body fluids; there is also reduced infant handling and heat loss because measuring from the tympanic membrane site is a very rapid measurement (2 to 5 seconds). There is no risk of injury to the patient or nurse when measuring from the temporal artery site, so there is no risk of exposure to body fluids. The axillary site is not recommended for measuring temperature in infants and young children.

The nurse in the pediatric intensive care unit is evaluating the vital signs of an infant born to an HIV-positive mother. The infant's temperature was high in previous readings. The blood reports of the infant are pending. What are the possible sites where temperature can be measured in this patient? Select all that apply. 1 Oral site 2 Rectal site 3 Axillary site 4 Temporal artery site 5 Tympanic membrane site

1, 2, 3 This is a typical case of accidental hypothermia in which the patient shows signs such as uncontrolled shivering and cyanosis; cardiac dysrhythmias may occur in later stages. The body may try to generate heat to counteract hypothermia by shivering. Hypothermia results in a decreased blood supply to the peripheral organs, resulting in cyanosis. Cardiac dysrhythmias may occur because the cells of the body cannot function at low temperatures. Blood pressure and respiratory rate tend to fall in hypothermia.

The nurse is assessing a patient who has just been rescued after falling into a frozen lake. The patient's body temperature has fallen below 93.2° F (34° C). Which signs should the nurse expect the patient to show? Select all that apply. 1 Cyanosed skin 2 Uncontrolled shivering 3 Cardiac dysrhythmias 4 Increased blood pressure 5 Increased respiratory rate

4 The normal acceptable range of respiratory rate is between 12 and 20 breaths per minute; hence, the patient has a reduced respiratory rate (bradypnea). The normal range of pulse pressure is between 30 and 50 mm Hg. The average rectal temperature is 99.5° F (37.5° C). The pulse rate of a normal patient should be in the range of 60 to 100 beats per minute.

The nurse is assessing a patient's vital signs. After assessment, the nurse immediately reports an unstable vital sign to the health care provider. What finding in the patient alerts the nurse to a deviation from the normal range? 1 Pulse pressure of 50 mm Hg 2 Rectal temperature of 99.5° F (37.5° C) 3 Pulse rate of 62 beats per minute 4 Respiratory rate of 11 breaths per minute

2, 1, 5, 3, 4 First, hand hygiene should be performed before assessing a patient to reduce transmission of microorganisms. The patient should be positioned comfortably by supporting the lower arm. The patient should be instructed to breathe normally to prevent fluctuations in respiratory rate and depth. The sensor probe should then be attached to the monitoring site. Finally, the probe should be left in place until the oximeter readout reaches a constant value.

The nurse is assessing oxygen saturation in a patient with chronic bronchitis. What is the correct order of steps to be implemented by the nurse? 1. Position patient comfortably 2. Perform hand hygiene 3. Attach sensor probe to the site 4. Leave probe until oximeter shows constant reading 5. Instruct patient to breathe normally

1 While measuring rectal temperature with an electronic thermometer, patients are positioned in Sims' position with the upper leg flexed to promote comfort. The sitting and supine positions are recommended for measuring blood pressure in patients with orthostatic hypertension, not for assessing rectal temperature. A patient with oxygen saturation (SpO2) less than 90% should be placed in a high-Fowler's position to improve ventilation.

The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort? 1 Sims' position 2 Sitting position 3 Supine position 4 High-Fowler's position

1, 3, 5 Adequate fluids should be provided to compensate for the fluid loss due to sweating and hypermetabolism. Physical activities would further increase core body temperature; therefore, they should be avoided to minimize heat production. Reducing the external covering of the patient's body would help to dissipate heat and decrease body temperature. Antibiotics should not be administered unless the causative pyrogen has been identified. The room temperature should be set at a lower, comfortable temperature of around 70° F (21° C) to 80° F (27° C).

The nurse is attending to a patient with fever. Which nursing interventions are appropriate when caring for this patient? Select all that apply. 1 Provide fluids. 2 Administer routine antibiotics. 3 Instruct patient to limit physical activity. 4 Set the room temperature between 86° F (30° C) and 93° F (34° C). 5 Reduce the external covering of the patient's body enough so that the heat dissipates but not so much that the patient begins to shiver.

Less than 12 The normal respiratory rate for an adult is 12 to 20 breaths/minute. Bradypnea is said to be present when breathing is regular and abnormally slow, in other words, less than 12 breaths/minute.

The nurse is caring for a patient who has bradypnea. Bradypnea is said to be present when breathing is regular but abnormally slow. How many less breaths per minute is that? Record your answer using a whole number. __ breaths/minute

2, 4, 5 The nurse should measure the vital signs before, during, and after the transfusion of blood products. The vital signs should be measured when the patient reports nonspecific symptoms of physical distress, such as feeling "funny" or "different." The nurse should measure vital signs in case of conditions that may influence vital signs, such as before performing range-of-motion (ROM) exercises, because the vital signs may vary while performing ROM exercises. The nurse would not measure vital signs when the patient is eating because eating would not have any influence on vital signs. The nurse should measure vital signs when the patient has increased intensity of pain, not decreased intensity.

The nurse is caring for a patient who underwent a hysterectomy. In which situation should the nurse measure the vital signs? Select all that apply. 1 When the patient eats 2 During the infusion of blood products 3 When the patient has decreased pain intensity 4 When the patient reports that she feels "different" 5 Before the patient performs range-of-motion exercises

1, 5 A tympanic thermometer is fast, safe, noninvasive, and can be used for patients complaining of tachypnea without affecting breathing. Hearing aids must be removed before measurement. Tympanic thermometers are not recommended for patients who have had a recent ear infection such as otitis media; using a tympanic thermometer may spread the infection and may measure inaccurately. Patients with cerumen impaction should not have their temperature measured through a tympanic thermometer, because it can give an erroneous reading. Surgery on the ear is a contraindication for use of the tympanic thermometer.

The nurse is conducting a class on different temperature measurement sites. In which patients should the tympanic membrane be used as a site for temperature measurement? Select all that apply. 1 In patients who do not mind the removal of their hearing aids 2 In patients with otitis media 3 In patients who had surgery of the ear 4 In patients with cerumen impaction 5 In patients complaining of tachypnea

3 Carotid pulses should not be assessed simultaneously, because excessive pressure on both the carotids may occlude blood supply to the brain. Radial and temporal pulses may be assessed simultaneously or individually without causing any harm to the patient. Simultaneous assessment of brachial pulses also has no adverse effects.

The nurse is evaluating the assessment skills of students by asking them to perform an assessment of vital signs. The nurse finds that a student is assessing the pulse in an improper way. Which assessment of the student leads the nurse to conclude this? 1 The student is assessing the radial pulses individually. 2 The student is assessing the temporal pulses individually. 3 The student is assessing the carotid pulses simultaneously. 4 The student is assessing the brachial pulses simultaneously.

1, 3 The apical and brachial pulse sites are the best for assessing an infant's or young child's pulse because the other peripheral pulses are deep and difficult to palpate accurately. The dorsalis pedis and posterior tibial pulse sites are used to assess circulation in the foot.

The nurse is evaluating the pulse of a 2-day-old infant in the pediatric unit. What are the best sites to assess the pulse in this case? Select all that apply. 1 Apical pulse 2 Radial pulse 3 Brachial pulse 4 Dorsalis pedis pulse 5 Posterior tibial pulse

2, 4 Meperidine and butorphanol are medications that reduce shivering. Wrapping the patient's extremities provides warmth and reduces shivering. The use of cooling fans, bathing with alcohol-water solutions, and placing of ice packs on the axillae and groin areas will take heat away from the body and increase the shivering.

The nurse is giving a tepid sponge bath to a patient. The patient suddenly starts shivering during the bath. How does the nurse manage the shivering of the patient? Select all that apply. 1 Use cooling fans. 2 Administer meperidine or butorphanol. 3 Have patient bathe with alcohol-water solutions. 4 Wrap the patient's extremities. 5 Apply ice packs to axillae and groin areas.

1, 2, 4 A relapsing fever is characterized by periods of febrile episodes and periods with acceptable temperature values. These episodes often last longer than 24 hours. A sustained body temperature continuously above 100.4° F (38° C) with little fluctuation is called a sustained fever. An intermittent fever is characterized by fever spikes interspersed with usual temperature levels. Fever spikes and falls without a return to normal temperature levels are found in remittent fever.

The nurse is learning about different types of fevers. Which statements are true about relapsing fever? Select all that apply. 1 It includes periods of febrile episodes and periods with acceptable temperature values. 2 Febrile episodes and periods of normothermia are often longer than 24 hours. 3 It is typified by a constant body temperature continuously above 100.4° F (38° C) and has little fluctuation. 4 It includes fever spikes interspersed with usual temperature levels. 5 It includes fever spikes and falls without a return to normal temperature levels.

3 The brachial pulse is used when measuring blood pressure. It can be located in the groove between the biceps and triceps muscles at the antecubital fossa. The radial pulse is located at the thumb side of the forearm at the wrist. This pulse is used to assess the circulation to the hand. The ulnar pulse is located at the ulnar side of the forearm at the wrist. This pulse is used to assess the circulatory status to the hand and to perform Allen's test. The apical pulse can be palpated at the fourth to fifth intercostal space at the left midclavicular line.

The nurse is measuring a patient's blood pressure. Where should the nurse locate the pulse to auscultate blood pressure? 1 Thumb side of forearm at wrist 2 Ulnar side of forearm at wrist 3 Groove between biceps and triceps muscles at antecubital fossa 4 Fourth to fifth intercostal space at left midclavicular line

3 Pulse pressure is defined as the difference between the systolic and diastolic blood pressure normally ranging from 30 to 50 mm Hg. Any value below 30 mm of Hg and above 50 mm of Hg is considered to be outside the normal range.

The nurse is measuring the vital signs of a patient. What is the normal range of pulse pressure? 1 10 to 15 mm Hg 2 20 to 25 mm Hg 3 30 to 50 mm Hg 4 60 to 70 mm Hg

3 The drug therapy for high blood pressure does not cure the disease; it only helps control the symptoms. Patients should check blood pressure regularly, report significant changes, and avoid the use of tobacco in any form. The blood pressure would return to normal with the drug therapy; however, therapy should not be stopped or hypertension may return.

The nurse is teaching a patient who is taking antihypertensive drugs about the management of hypertension. Which statement would indicate that the patient understands the management of hypertension? 1 "I need to have my blood pressure checked monthly." 2 "I can still smoke while taking these drugs as long as I cut down." 3 "These pills will help control my high blood pressure." 4 "When my blood pressure is back to normal, I can stop taking these pills."

2, 5 Vital signs should be measured before, during, and after a transfusion of blood products, not only before and after. During the blood transfusion, it is important to measure vital signs to check the occurrence of any complication due to transfusion rate or amount of blood product transfusion. Vital signs should be measured before, during, and after the administration of medication that affects temperature control functions, not only after. Before the administration of medication that affects temperature control, it is important to measure vital signs to determine whether the patient is really in need of that medication. During the administration of medication that affects temperature control, it is important to measure the vital signs to check for overdosing. Vital signs should be measured before a patient previously on the bed ambulates. Vital signs should be measured after a patient reports increased intensity of pain. Vital signs should be measured before a patient performs range-of-motion exercises.

The nurse is teaching the nursing student about when to measure the vital signs in a patient. Which statement by the nursing student indicates the need for further learning? Select all that apply. 1 "Vital signs should be measured before ambulating a patient previously on bed rest." 2 "Vital signs should be measured before and after a transfusion of blood products." 3 "Vital signs should be measured after a patient reports increased intensity of pain." 4 "Vital signs should be measured before a patient performs range-of-motion exercises." 5 "Vital signs should be measured after the administration of medication that affects temperature control functions."

2, 3, 4 When the nurse is unable to obtain BP readings, a Doppler ultrasound stethoscope should be used to assess a weakened pulse rate because it enhances the pulse sounds and the accuracy of the assessment. The nurse should assess for signs of decreased cardiac output and report it to the head nurse or health care provider. The nurse should immediately determine that no crisis is present by obtaining the pulse and respiratory rate. An alternative site or procedure to obtain a BP reading should be used, such as auscultating in a lower extremity or using a Doppler ultrasonic device. Using electronic devices may not be of much help if the BP cannot be recorded with the sphygmomanometer. Measuring BP in another arm and comparing the findings is not required in this case. It is required when the BP is found to be above the normal range.

The nurse is unable to obtain the blood pressure (BP) reading of a patient using a sphygmomanometer. The sphygmomanometer is working correctly. What should the nurse do next? Select all that apply. 1 The nurse should use an electronic BP device. 2 The nurse should use a Doppler ultrasonic device. 3 The nurse should assess for signs of reduced cardiac output. 4 The nurse should measure the patient's pulse and respiratory rate. 5 The nurse should measure BP in another arm and compare findings.

2 When a patient shows periods of febrile episodes alternating with acceptable normal body temperatures, with both often lasting longer than 24 hours, it is called relapsing fever. Sustained fever is the body temperature that is constant, with a little fluctuation. When fever spikes and falls without returning to normal temperature, it is called remittent fever. Intermittent fever is associated with spikes interspersed with a return to normal temperature levels at least once within 24 hours.

The nurse notes that the patient has been experiencing febrile episodes lasting more than 24 hours interrupted by periods of normal body temperature that also last than 24 hours. What does the nurse infer about the patient's fever pattern? 1 Sustained fever 2 Relapsing fever 3 Remittent fever 4 Intermittent fever

2 The difference between the apical and radial pulse rates is the pulse deficit. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. Pulse deficits are often associated with abnormal rhythms. Peripheral and apical pulse rate assessment often reveals variations in heart rate, but the difference in these pulses is not associated with abnormalities in heart rate. Blood pressure and respiratory rate abnormality may be associated with pulse rate, not pulse deficit.

The registered nurse (RN) observes a difference between a patient's apical pulse and radial pulse rates. Which parameter abnormality is most likely to be associated with this difference in pulses? 1 Heart rate 2 Heart rhythm 3 Blood Pressure 4 Respiratory rate

1 Hypothermia is the condition in which the skin temperature drops below 34° C (or 93.2° F). The patient exhibits various signs, such as the bluish discoloration of the skin or cyanotic skin. Ice crystals formed inside the cells of the patients with frostbite may cause permanent circulatory damage or tissue damage. Malignant hyperthermia is a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. Patients are at a risk of heatstroke when they are on medication therapy with certain drugs that decrease the ability of the body to lose heat, such as diuretics, amphetamines, and beta adrenergic receptor antagonists.

The registered nurse is teaching a nursing student about alterations in body temperature outside the normal range. Which statement by the nursing student indicates the need for further teaching? 1 "Bluish discoloration of the skin is noticed in patients with elevated body temperature." 2 "Ice crystals that form inside the cells of the patients with frostbite may cause tissue damage." 3 "Malignant hyperthermia is an inherited condition that results in uncontrollable heat production." 4 "Patients who are on diuretic and amphetamine medication therapy are at a high risk of heatstroke."

3, 5 Nursing interventions are important for patients who have fever. Excessive activity such as turning and ambulation increases oxygen demands and heat production; therefore, the nurse should advise the patient to limit such activities and increase rest periods. Providing 8 to 10 glasses of fluids is a safety requirement for increased metabolic rate. Reducing external covering on the patient would help maximize heat loss from the body. Application of a damp cloth to the patient's forehead promotes comfort but does not minimize heat production.

The registered nurse is teaching a nursing student about interventions that should be performed for patients with fever to minimize heat production. Which interventions performed by the nursing student reflect effective learning? Select all that apply. 1 Providing 8 to 10 glasses of fluids per day 2 Applying a damp cloth to the patient's forehead 3 Encouraging the patient to increase rest periods 4 Reducing external covering on the patient's body 5 Advising the patient to avoid turning and ambulating excessively

2 Patients should avoid performing strenuous exercises in hot and humid weather, because the exercise will increase heat production in the body. Loose fitting, light colored, and light clothes should be encouraged to avoid heat production. A balance between heat production and heat loss should be maintained to promote the health of patients at risk for imbalanced body temperature. Drinking fluids such as water and clear fruity juices before, during, and after exercise should be recommended.

The registered nurse is teaching a nursing student about promoting health to manage body temperature. Which statement by the nursing student indicates a need for further teaching? 1 "Loose fitting and light colored clothes should be encouraged." 2 "Strenuous exercise in hot and humid weather is permitted." 3 "The balance between heat production and heat loss should be maintained." 4 "Water and clear fruity juices should be encouraged before, during, and after exercise."

4 The tympanic membrane site is easily accessible for measuring body temperature, but it requires minimal repositioning of the patient. The rectal site for temperature measurement may have a risk of body fluid exposure and injury to the rectal lining. Therefore, before assessing temperature, the site should be lubricated. Skin is a safe noninvasive site for temperature measurement. The oral site for temperature measurement is not used for infants, small children, or patients who are confused, unconscious, or uncooperative.

The registered nurse is teaching a nursing student about the advantages and disadvantages of selecting temperature measurement sites. Which statement by the nursing student indicates the need for further teaching? 1 "The rectal site for temperature measurement requires lubrication." 2 "Skin is a safe and non-invasive site for temperature measurement." 3 "The oral site for temperature measurement is contraindicated in infants and children." 4 "The tympanic membrane site is easily accessible without changing position to measure temperature."

1 Older adults usually lose upper arm mass and require a smaller blood pressure cuff. Changing the patient's position will help reduce the risk of postural hypotension. The skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. Therefore, it is advised to make frequently assess the skin under the cuff and rotate blood pressure sites.

The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching? 1 "I should use a large cuff to measure blood pressure." 2 "I should instruct the patient to slowly change his or her position." 3 "I should assess the skin while frequently monitoring the blood pressure." 4 "I should rotate the sites for measurement of blood pressure for frequent monitoring of blood pressure."

4 When blood pressure is above the acceptable range, the nurse should verify the correct size and placement of the cuff, because the cuff size may alter the readings if not placed properly. Administering vasoconstricting drugs may lead to a further increase in blood pressure. Placing the patient in the supine position would not have the effect of lowering the blood pressure, because the supine position mainly enhances circulation and restricts activity if there is decreased blood pressure. The nurse should increase the rate of intravenous infusion when the blood pressure is not sufficient for adequate perfusion and oxygenation of tissues.

The registered nurse is teaching a student nurse about the interventions to be followed when the blood pressure is above the acceptable range. Which statement by the nursing student indicates effective learning? 1 "I should administer vasoconstricting drugs." 2 "I should place the patient in the supine position." 3 "I should increase the rate of intravenous infusion." 4 "I should verify the correct size and placement of the cuff."

4 The nurse should obtain blood pressure (BP) readings within 3 minutes after the patient changes position because in most of the cases, orthostatic hypotension is detected within a minute of changing the position. While observing orthostatic measurements, the nurse should observe for other symptoms, such as blurred vision, weakness, and light-headedness. Orthostatic hypotension should be assessed by obtaining BP and pulse in sequence when the patient is sitting and standing. While recording the orthostatic BP measurements, the nurse should record the patient's position in addition to the BP measurement,for example,"140/80 mm Hg supine."

The registered nurse teaches a nursing student about the assessment of vital signs in a patient with orthostatic hypotension. Which statement made by the nursing student indicates a need for further learning? 1 "I should assess for blurred vision while obtaining orthostatic measurements." 2 "I should measure blood pressure and pulse in sequence when the patient is sitting." 3 "I should record the patient's position along with the blood pressure measurement." 4 "I should measure blood pressure within 30 minutes after the patient changes position."

4 Vital signs are the rapid and efficient way of monitoring a patient's condition. These signs help to identify problems and to evaluate the patient's response to interventions. The nurse is responsible for judging the frequency of assessment of these signs. The nurse should measure vital signs every five to 10 minutes when the physical condition of the patient worsens.The nurse should measure vital signs during home care visits. The vital signs should also be monitored before, during, and after a surgical procedure. When a patient reports nonspecific symptoms of physical distress, the nurse should assess the vital signs.

The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning? 1 "I will assess the vital signs during home care visits." 2 "I will assess the vital signs before, during, and after a surgical procedure." 3 "I will assess the vital signs of a patient who reports nonspecific symptoms of physical distress." 4 "I will assess the vital signs every hour when the physical condition of the patient worsens."

4 Temperature is one of the most stable rhythms in humans. Circadian body temperature rhythm normally changes 0.5 to 1° C (0.9 to 1.8° F) during a 24-hour period. Physical and emotional stress increases body temperature through hormonal and neural stimulation, but these stressors are not associated with a 0.5 to 1° C change in body temperature during a 24-hour period. Prolonged strenuous exercise, such as long-distance running, temporarily raises body temperature. Hormonal variations during the menstrual cycle cause body temperature fluctuations. Woman who have stopped menstruating often experience periods of hot flashes, in which skin temperature increases up to 4° C (7.2° F).

Which factor is associated with a 0.5 to 1° C change in body temperature during a 24-hour period? 1 Stress 2 Exercise 3 Hormonal level 4 Circadian rhythm

3 Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.

Which patient is most at risk for tachycardia? 1 A healthy professional tennis player 2 A patient admitted with hypothermia 3 A patient with a fever of 39.4° C (103° F) 4 A 90-year-old male taking beta blockers

1, 2 Rib fractures would cause splinting and pain that increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.

Which patients are most at risk for tachypnea? Select all that apply. 1 A patient just admitted with four rib fractures 2 A woman who is 9 months pregnant 3 An adult who has consumed alcoholic beverages 4 An adolescent awaking from sleep 5 A patient who regularly runs marathons

1, 2 Rib fractures would cause splinting and pain that increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.

Which patients are most at risk for tachypnea? Select all that apply. 1 A patient just admitted with four rib fractures 2 A woman who is 9 months pregnant 3 An adult who has consumed alcoholic beverages 4 An adolescent awaking from sleep 5 A patient who regularly runs marathons

4 Kyphosis in older patients may restrict chest expansion. The subtle changes in temperature may cause anorexia. In older patients, decreased sweat gland reactivity may cause hyperthermia. Older patients are instructed to change position slowly to prevent postural hypotension.

What consequence may occur due to kyphosis in an older patient? 1 Anorexia 2 Hyperthermia 3 Postural hypotension 4 Restricted chest expansion

2 The acceptable range for diastolic blood pressure in a healthy adult is less than 80 mm Hg. Less than 120 mm Hg is the acceptable range for systolic blood pressure in a healthy adult. The normal range for pulse pressure in a healthy adult is 30 to 50 mm Hg. The normal range for capnography in a healthy adult is 35 to 45 mm Hg.

What is the acceptable range for diastolic blood pressure in a healthy adult? 1 Less than 120 mm Hg 2 Less than 80 mm Hg 3 30 to 50 mm Hg 4 35 to 45 mm Hg

3 The average tympanic temperature for adults is 37° C (98.6° F). A body temperature of 96.8° F is within the normal range for adults. The average axillary temperature for adults is 36.5° C (97.7° F). The average rectal temperature for adults is 37.5° C (99.5° F).

What is the acceptable tympanic body temperature for adults? 1 36° C (96.8° F) 2 36.5° C (97.7° F) 3 37° C (98.6° F) 4 37.5° C (99.5° F)

3 The average rectal temperature of adults is 99.5° F. The axillary temperature of adults is 97.7° F. The average oral or tympanic temperature of adults is 98.6° F. Normal temperature range is between 96.8 and 100.4° F.

What is the average rectal temperature of a 35-year-old adult? 1 36.5° C (97.7° F) 2 37° C (98.6° F) 3 37.5° C (99.5° F) 4 38° C (100.4° F)

2, 6, 1, 5, 4, 3 While measuring axillary temperature with an electronic thermometer, the nurse should first help the patient to a supine or sitting position. Then, the thermometer pack should be removed from the charging unit and thoral thermometer stem or blue tip should be attached to the thermometer unit. Next, the nurse should raise the patient's arm away from the torso and insert the thermometer probe into the center of the axilla. Once the probe is positioned, the nurse should hold the thermometer probe in place until there is an audible signal that indicates completion, and the patient's temperature appears on the digital display. Finally, the ejection button should be pushed on the thermometer stem to discard the plastic probe cover into an appropriate receptacle.

What is the correct order of steps involved in axillary temperature measurement with an electronic thermometer? 1. Raising the patient's arm away from the torso 2. Helping the patient to a sitting position 3. Pushing the ejection button on the thermometer stem 4. Holding the thermometer until there is audible signal 5. Inserting the thermometer probe into the center of the axilla 6. Attaching the blue tip of the probe stem to the thermometer unit

4, 1, 5, 6, 3, 2 To measure rectal temperature using an electronic thermometer, the patient should be positioned by flexing the upper leg. Then, the anal region should be cleaned while wearing gloves, and the gloves should be removed after cleaning, with new clean gloves reapplied. Next, the rectal probe stem should be attached to the thermometer unit and a plastic disposable probe cover should be slid on. A liberal portion of lubricant is squeezed and applied on the tissue. Finally, the thermometer probe should be inserted into the anus.

What is the correct order of steps when measuring rectal temperature? 1. Cleaning the anal region by wearing gloves 2. Inserting the thermometer probe into the anus 3. Squeezing a liberal portion of lubricant on tissue 4. Helping the patient into position with upper leg flexed 5. Attaching rectal probe stem to the thermometer unit 6. Sliding disposable plastic probe cover over the probe stem

4 Increased temperature reduces the concentration of iron in the blood plasma, suppressing the growth of bacteria. Heart and respiratory rates increase to meet the metabolic needs of the body during fever conditions. Body metabolism increases 10 percent for every degree (Celsius) of temperature elevation. When there is a rise in temperature, cellular metabolism increases, thereby increasing the oxygen consumption.

Which alteration in the body is prominent when there is a rise in body temperature? 1 Decreased respiratory rate 2 Decreased body metabolism 3 Decreased oxygen consumption 4 Decreased concentration of iron in the blood

4 The brachial site is suitable for assessing circulation in the lower arm and auscultating blood pressure. The ulnar site is used to assess circulation to the hand. The apical site is suitable for auscultating the apical impulse. The carotid site is easily accessible and is used during shock and cardiac arrest.

Which arterial site does the nurse choose to assess circulation to the lower arm and auscultate blood pressure? 1 Ulnar site 2 Apical site 3 Carotid site 4 Brachial site

1 Radial pulse is used to teach patients about monitoring their heart rate, mainly for athletes and people taking heart medications. When the radial pulse is abnormal or intermittent due to dysrhythmias, or if it is inaccessible because of a dressing or cast, the apical pulse can be assessed in the patient. The carotid site is recommended for quickly finding and assessing the pulse. The brachial pulse is the best site for assessing pulse in an infant or a young child. Temporal pulse is used to assess pulse in children because it is easily accessible.

Which pulse is used by the nurse to teach athletes to monitor their heart rate? 1 Radial pulse 2 Carotid pulse 3 Brachial pulse 4 Temporal pulse

4 The temporal site is easily accessible and is suitable for assessing a pulse in children. The radial site is used to assess the status of circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The femoral site is an easily accessible site during shock and cardiac arrest, and this site is suitable for assessing circulation in the legs. The brachial or apical pulse is the best site for assessing the pulse in an infant or young child

Which site is appropriate for assessing the pulse in children? 1 Radial 2 Carotid 3 Femoral 4 Temporal

2 The radial site is used to assess the status of circulation and is the preferred site when assessing the heart rate in a patient. The carotid site is present in the neck along the medial edge of the sternocleidomastoid muscle. The pulse rate is assessed from the carotid site when other sites are not palpable in a patient with cardiac arrest. The apical site is used to assess apical pulse rate. The temporal site is used to assess pulse rate in children.

Which site is preferred for assessing the heart rate in a patient? 1 Apical 2 Radial 3 Carotid 4 Temporal

3 It takes longer for the heart rate to rise in the older adults during illness to meet increased demands during conditions such stress, illness, and excitement. Pedal pulses are often difficult to palpate in older adults. Older adults have decreased heart rate at rest. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.

Which statement is true regarding the pulse rate of an older adult? 1 Pedal pulse can easily be palpated in older adults. 2 Older adults have increased heart rate at rest. 3 It takes longer for the heart rate to rise in older adults during illness. 4 Heart sounds are sometimes muffled due to decreased air space in the lungs.

1, 2, 3 It is important to be attentive to subtle temperature changes and other manifestations of fever in older adults. Older adults are very sensitive to slight changes in environmental temperature, because their thermoregulatory systems are not as efficient. A decrease in sweat gland reactivity in the older adults results in a higher threshold for sweating at high temperatures that leads to hyperthermia and heatstroke. Older adults are often missing teeth and have poor muscle control; therefore, they may be unable to close their mouth tightly to obtain accurate oral temperature readings. The temperature of older adults is at the lower end of the normal temperature range.

Which statements are true regarding the factors affecting vital signs of older adults? Select all that apply. 1 It is important to pay attention to subtle temperature changes in older adults. 2 Older adults are very sensitive to slight changes in environmental temperature. 3 A decrease in sweat gland reactivity in older adults may lead to hyperthermia. 4 The oral site is best for taking accurate temperature readings in older adults. 5 The temperature of the older adult is at the upper end of the normal temperature range.

3 Along with the actual vital signs, there will be symptoms accompanied with it. Elevated body temperature results in diaphoresis. Cyanosis is associated with hypoxemia. Chest pain occurs due to abnormal blood pressure. Abnormal respirations result in shortness of breath.

Which symptom is associated with an elevated temperature? 1 Cyanosis 2 Chest pain 3 Diaphoresis 4 Shortness of breath

2 Decreased vessel elasticity will alter the systolic blood pressure. Pulse rate, respiratory rate, and body temperature are not altered by decreased vessel elasticity.

Which vital parameter may be altered due to decreased vessel elasticity? 1 Pulse rate 2 Blood pressure 3 Respiratory rate 4 Body temperature

1, 2 The normal range of pulse oximetry in an adult is SpO2 ≥ 95%; therefore, a pulse oximetry value of 92% is low. The normal range of pulse pressure in an adult is 30-50 mm Hg; therefore, a pulse pressure value of 60 mm Hg is high. The average axillary temperature in a normal adult is 36.5° C (97.7° F). The normal range of pulse rate in an adult is 60-100 beats per minute. The normal range of respiratory rate in an adult is 12-20 breaths per minute.

Which vital values in a patient are abnormal? Select all that apply. 1 Pulse oximetry 92% 2 Pulse pressure 60 mm Hg 3 Axillary temperature 97.7° F 4 Pulse rate 80 beats per minute 5 Respiratory rate 18 breaths per minute

3 Kyphosis is the abnormal curvature of the spine observed in older adults, which causes restriction of chest expansion and decreased tidal volume. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. Poor muscle control does not cause decreased tidal volume. Decrease in sweat gland activity in older adults results in a higher threshold for sweating at high temperature and leads to hyperthermia and heatstroke.

While assessing the condition of a 70-year-old patient, the nurse observes decreased tidal volume. What is the likely reason for this observation? 1 Poor muscle control 2 Increased air space in lungs 3 Abnormal curvature of the spine 4 Decreased sweat gland reactivity

3 Heart sounds maybe muffled or difficult to hear in older adults due to an increase in air space in the lungs. An increase in heart rate would show differences in pulse rate, not differences in heart sounds. Older adults may experience an increase in systolic pressure due to decreased vessel elasticity. Ossification of costal cartilage for older adults results in reduced chest wall expansion.

While assessing the pulse rate of an 80-year-old patient, the nurse has difficulty hearing the heart sounds of the patient. What could be the reason for the muffled heart sounds? 1 Increased heart rate 2 Decreased vessel elasticity 3 Increased air space in lungs 4 Ossification of costal cartilage

2 Capnography is the measurement of exhaled carbon dioxide throughout exhalation. Interpretation of a continuous recording, or capnogram, can detect changes in ventilation. The ETCO2 value can be used to evaluate respiratory and cardiac status. Electrocardiogram interpretation is most appropriate for interpreting changes in heart rate and rhythm. Capnography approximates the partial pressure of carbon dioxide, but may not determine the changes in the partial pressure of oxygen.

While caring for a patient with a respiratory disorder, which abnormality can be most appropriately interpreted by the primary health care provider from the continuous recordings of the capnogram? 1 Changes in heart rate 2 Changes in ventilation 3 Changes in heart rhythm 4 Changes in partial pressures of oxygen

4 When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is: You will get a false-high reading. If the bladder or cuff were too wide, the reading would be a false-low reading.

You observe a nursing student taking a blood pressure (BP) reading on a patient. The patient's BP range over the past 24 hours was 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which BP reading made by the student is most likely caused by the incorrect choice of BP cuff? 1 96/40 mm Hg 2 110/66 mm Hg 3 130/70 mm Hg 4 156/82 mm Hg