Module 3 vital signs
The student nurse is unsure of the BP measurement. What should the student nurse do first? -Wait 30 seconds and repeat the measurement on the same arm. -Assess the BP in the other arm. -Get the nurse to assess the BP. -Determine if the patient received an antihypertensive medication.
-Assess the BP in the other arm.
The NAP reports to the nurse a 65-year-old patient's blood pressure is 160/98. What is the appropriate initial response of the nurse? -Ask the NAP if the patient is nauseous. -Assess the patient's blood pressure. -Instruct the NAP to obtain a full set of vital signs. -Document this as a normal finding in an elderly adult.
-Assess the patient's blood pressure.
If a patient has dysphagia (difficulty swallowing), which of the following foods found on the patient's tray may be cause for concern or require further intervention? (Select all that apply.) -Grape juice. -Oatmeal. -Sausage patty. -Toast with butter. -Scrambled eggs.
-Grape juice. -Sausage patty. -Toast with butter.
The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best action by the nurse at this time? -Request the NAP obtain the patient's pulse oximetry and report back. -Ask the NAP to obtain and document a full set of vital signs. -Assess the patient, including the pulse oximetry reading. -Notify the health care provider of this change in condition.
-Assess the patient, including the pulse oximetry reading.
Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? -Check the carotid pulses one side at a time. -Auscultate the apical pulse for quality and rate. -Reassess the radial pulse for 30 seconds. -Check the radial pulse on the opposite side.
-Auscultate the apical pulse for quality and rate.
A nursing student is assigned to take the vital signs on a patient and finds the radial pulse to be irregular. What action should the nursing student take? -Ask a fellow student to assess the pulse. -Auscultate the patient's apical pulse. -Wait 15 minutes and reassess the pulse. -Check the patient's previous pulse reading.
-Auscultate the patient's apical pulse.
The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used. (Select all that apply.) -Blue probe electronic thermometer. -Red probe electronic thermometer. -Chemical oral thermometer. -Chemical external thermometer. -Tympanic thermometer. -Thermometer cover. -Lubricant. -Watch with second hand. -Patient data recording sheet and a pen. -Tissue.
-Blue probe electronic thermometer. -Thermometer cover. -Patient data recording sheet and a pen.
The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply.) -The patient's age. -The type of temperature required. -The patient's diagnosis. -The frequency for taking or monitoring the temperature. -What changes to report immediately to the nurse.
-The type of temperature required. -The frequency for taking or monitoring the temperature. -What changes to report immediately to the nurse.
How can the nurse best obtain an accurate measurement of a patient's respiratory rate? -Inform the patient when monitoring his or her respirations. -Assess the respirations while the patient is talking. -Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. -Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
-Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) -Count the respiratory rate again for a full 60 seconds (1 minute). -Tell the patient their breaths are being counted so the patient will breathe slower. -Assess physiologic factors that may be causing the patient to breathe so fast. -Administer a bronchodilator that will decrease the respiratory rate. -Record this normal respiratory rate in the patient's medical record.
-Count the respiratory rate again for a full 60 seconds (1 minute). -Assess physiologic factors that may be causing the patient to breathe so fast.
Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) -An elderly patient with Type 1 diabetes who is otherwise healthy. -The patient who was just informed of a diagnosis of cancer. -A patient with peripheral vascular disease. -A patient who is receiving bolus IV fluids. -A patient with Alzheimer's disease
-The patient who was just informed of a diagnosis of cancer. -A patient with peripheral vascular disease. -A patient who is receiving bolus IV fluids.
The nurse checks the patient's extremity restraints hourly. What is the nurse looking for specific to this type of restraint? (Select all that apply.) -Distal pulses. -Temperature of the skin distal to the restraint. -Whether the patient wants the restraints released. -Proper placement of the restraint. -The character of respirations. -Sensation of the distal part of the extremity. -The patient's blood pressure. -Color of skin distal to the restraint.
-Distal pulses. -Temperature of the skin distal to the restraint. -Proper placement of the restraint. -Sensation of the distal part of the extremity. -Color of skin distal to the restraint.
Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) -Drinking a cold glass of water. -Participation in physical therapy exercises. -Infection. -Room temperature. -Patient's height.
-Drinking a cold glass of water. -Participation in physical therapy exercises. -Infection. -Room temperature.
A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would likely be the least restrictive and most effective? -Mitten restraint. -Extremity restraint. -Elbow restraint. -Belt restraint.
-Elbow restraint.
For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? -A patient who is a double arm amputee following a motor vehicle accident. -A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). -A patient with a history of a right-sided cerebrovascular accident (stroke). -A patient with an arteriovenous shunt located in the forearm for hemodialysis.
-A patient with a deep vein thrombosis (blood clot, usually in the lower extremities).
Which patient would it be appropriate for the nurse to delegate vital signs? -New admission to the hospital. -Patient transferred from ICU. -Elderly nursing home resident. -Patient with recent complaint of headache.
-Elderly nursing home resident.
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) -An apical pulse of a patient who is to receive a cardiac drug. -A radial pulse on a patient with a 1200 mL fluid restriction. -A radial pulse of a patient in the emergency room with chest pain. -A femoral pulse following a lower leg amputation. -The temporal pulse of a child.
-A radial pulse on a patient with a 1200 mL fluid restriction. -The temporal pulse of a child.
The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. -True. -False.
-False.
The daughter of an elderly patient comes to visit her mother, who was recently admitted to the hospital. The daughter notices a yellow band on her mother's wrist and asks what it is for. The nurse correctly responds that it is used to identify patients who are at risk for falling and provides additional information as to what makes a patient a fall risk. What information should the nurse include? (Select all that apply.) -Age over 65. -New and different environment. -Continent of urine and bowel. -History of a fall. -Having an IV. -Taking muscle relaxants.
-Age over 65. -New and different environment. -History of a fall. -Having an IV. -Taking muscle relaxants.
Who would the nurse expect to have the highest body temperature reading? -An elderly African-American male. -A teenager playing video games. -A preterm baby who is sleeping. -An adult female who is walking.
-An adult female who is walking.
Which of the following should the nurse report to the health care provider? -A young adult with a blood pressure of 110/70. -An elderly male with a temperature of 96.8°F (36°C). -A newborn with a respiratory rate of 40. -An adult patient with a heart rate of 55.
-An adult patient with a heart rate of 55.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? -"Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." "-Since the soup was not hot, go ahead and take the patient's temperature." -"Change to the red thermometer probe and take the patient's temperature rectally." -"Take the patient's temperature using the axillary route and when you record the reading, add 1°F."
-"Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? -"I will turn the continuous pulse oximetry alarms off at night so you can sleep." -"I can give you a back massage to help you relax before bedtime." -"If the finger clip is bothering you, I can attach a probe to your ear." -"I will notify the nurse that you need your sleeping medication tonight."
-"I will turn the continuous pulse oximetry alarms off at night so you can sleep."
What is the normal pulse range for an adult? -120 to 160 beats per minute. -90 to 140 beats per minute. -60 to 100 beats per minute. -50 to 80 beats per minute.
-60 to 100 beats per minute.
The nurse was assigned to care for five patients. Which of the following vital sign measurements would be cause for concern? (Select all that apply.) -88-year-old with temperature of 96.8° F (36° F) -75-year-old with pulse oximetry of 88% on room air -22-year-old with heart rate of 90 beats/minute -8-year-old with respiratory rate of 24 breaths/minute -65-year-old with blood pressure of 140/90
-75-year-old with pulse oximetry of 88% on room air -65-year-old with blood pressure of 140/90
A 15-year-old male patient is hypothermic. Which temperature reflects hypothermia? -95° F (35°C). -99° F (37.2°C). -101° F (38.3°C). -110° F (43.3°C).
-95° F (35°C).
If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? -37-39 °C (98.6-102.2 °F) -96.8-100.4 °F (36-38 °C) -35-36 °C (95-96.8 °F) -96.8-98.6 °F (36-37 °C)
-96.8-100.4 °F (36-38 °C)
A patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be? -97.8°F (36.5°C), 110, 24, 80/40 -98.6°F (37°C), 84, 20, 120/80 -99.0°F (37.2°C), 88, 16, 130/80 -100.4°F (38°C), 76, 24, 140/90
-97.8°F (36.5°C), 110, 24, 80/40
Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? -An African-American patient with a systolic BP of 100. -A football player with a diastolic BP of 94. -An elderly patient with a systolic BP of 88. -A pregnant woman with a diastolic BP of 67.
-A football player with a diastolic BP of 94.
Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) -A patient receiving a blood transfusion for chronic anemia. -An elderly patient who needs assistance with feeding and dressing. -An adult female in the recovery room following a hysterectomy. -A child who is below the normal height and weight for his age. -A young adult with a white blood count of 15,000/mm3.
-A patient receiving a blood transfusion for chronic anemia. -An adult female in the recovery room following a hysterectomy. --A young adult with a white blood count of 15,000/mm3.
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) -A newborn following a heelstick. -A patient returning from the operating room. -A patient who received morphine for pain. -A student who is getting ready to take an exam. -A patient who experienced a bleeding episode.
-A patient returning from the operating room. -A patient who received morphine for pain.
Which patient is at high risk for for the pulse oximetry alarm to sound? -A patient with a continuous pulse oximetry reading of 84%. -A patient who is receiving oxygen via face mask. -A patient who has an intermittent pulse oximetry reading of 95%. -A patient with a heart rate of 64 beats per minute.
-A patient with a continuous pulse oximetry reading of 84%.
Which of the following patients would require follow-up? -A child with a respiratory rate of 20 breaths per minute. -An adolescent with a respiratory rate of 16 breaths per minute. -An adult with a respiratory rate of 10 breaths per minute. -A newborn with a respiratory rate of 40 breaths per minute.
-An adult with a respiratory rate of 10 breaths per minute.
The nurse reads the following entry in a patient's health record. The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action? 01/25/17 0800 Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient's fingers cool to touch. Patient states has artificial nails. Patient on 2 L oxygen per nasal cannula. Respirations nonlabored. C. Smith, N.A.P.__ -Remove one of the patient's acrylic nails and reattempt obtaining the SpO2. -Place the patient's hands under warm running water and reattempt the reading. -Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading. -Nothing further, as the NAP has provided sufficient data regarding patient condition.
-Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading.
The nurse is caring for an elderly person who has suffered a stroke and now has left-sided weakness and dysphagia. The nurse is being careful to prevent the patient from aspirating by taking which of the following measures? (Select all that apply.) -Having the patient maintain an upright position for 30 to 60 minutes after eating. -Placing the food on the patient's left side of the mouth. -Placing the food in the middle of the tongue toward the back of the mouth. -Having the patient tilt her head forward slightly when swallowing. -Placing several tablespoons of food in the patient's mouth following it with liquid prior to having the patient swallow.
-Having the patient maintain an upright position for 30 to 60 minutes after eating. -Having the patient tilt her head forward slightly when swallowing.
-Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84 -Image A = 126/76, Image B = 140/90, Image C = 138/84, Image D = 120/80 -Image A = 140/90, Image B = 138/84, Image C = 120/80, Image D = 126/76 -Image A = 138/84, Image B = 120/80, Image C = 126/76, Image D = 140/90
-Image A = 120/80, Image B = 128/76, Image C = 140/90, Image D = 138/84
The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? -In the right arm -In the left arm -In the right leg -In the left leg
-In the right arm
What should the nurse do prior to applying physical restraints? -Initially, provide a restraint-free environment. -Warn the patient that restraints will be used if he or she does not cooperate. -Move the patient to a room without a roommate and away from the nurses' station. -Wait until the patient has actually fallen.
-Initially, provide a restraint-free environment.
What is the purpose of a gait belt? -It keeps patients from ambulating too fast by holding onto them. -It provides a means to steady a patient at the center of gravity. -It measures the distance a patient has ambulated by counting steps. -It identifies patients who are at risk for a fall and require assistance. -It is a type of restraint used as a safety measure.
-It provides a means to steady a patient at the center of gravity.
When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? -Have another nurse assess the patient's respiratory rate. -Remove the patient's gown for better visualization of the patient's chest. -Document the inability to visualize inspiration and expiration. -Move the patient's arm over their chest and feel the rise and fall of the chest.
-Move the patient's arm over their chest and feel the rise and fall of the chest.
A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? -Notify the health care provider for follow-up evaluation. -Tie the restraints to the bedside rail or frame of the wheelchair. -Tie the restraint straps in a knot so the patient does not get loose. -Assess, but avoid removing the restraints every 2 hours because the patient is violent.
-Notify the health care provider for follow-up evaluation.
The nurse reads the following nurse's note in the patient's health record. What is the priority nursing intervention based on this information? 9/21/17 1800 Patient complains of headaches, almost daily, occurring more frequently in the evening. BP 164/98. P. Johnson N.A.P. -Obtain a complete set of vital signs and gather further assessment data. -Administer acetaminophen (Tylenol) to relieve the patient's headache. -Inform the patient it is normal to have a higher BP reading in the evening. -Instruct the NAP to repeat the BP measurement using a manual cuff.
-Obtain a complete set of vital signs and gather further assessment data.
A patient has been given an opioid analgesic (e.g., morphine) for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose? -To see if the patient's complaints of pain are supported physiologically. -To reduce the addiction potential to unnecessary pain medication. -Opioid analgesics may depress rate and depth of respirations. -Assessment will provide the patient with a sense of security and reduce anxiety.
-Opioid analgesics may depress rate and depth of respirations.
You are taking a patient's BP by using the one-step method. Which of the following is an incorrect step in the sequence for performing this procedure? -Perform hand hygiene. Select the appropriate-size cuff. With the patient sitting, place the forearm at heart level, palm up. Provide privacy and explain the procedure. -Expose the arm and apply the cuff around the upper arm. Palpate for a brachial pulse. Place the stethoscope in your ears and place the diaphragm over the site of the brachial pulse. -Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg. -Listen for the last Korotkoff sound in mm Hg. Completely deflate the cuff and remove it from the patient's arm. Make the patient comfortable. Perform hand hygiene. Document the result.
-Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg.
The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) -Start oxygen at 2 liters per minute by nasal cannula. -Reassess the patient's pulse oximetry. -Place the patient in the high-Fowler's position. -Have the NAP take the patient's vital signs. -Assess the patient's respiratory and cardiac status.
-Reassess the patient's pulse oximetry. -Place the patient in the high-Fowler's position. -Assess the patient's respiratory and cardiac status.
The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading? (Select all that apply.) -Reduce environmental noise by turning off the TV or closing the -door. -Make sure the stethoscope does not touch the patient's clothing or BP cuff. -Keep the stethoscope tubing still to avoid extraneous sound. -Ensure the chest piece is rotated to the diaphragm side. -Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery. -Use a different stethoscope with longer tubing for improved conduction of sound. -Use the bell side of the stethoscope to auscultate the blood pressure.
-Reduce environmental noise by turning off the TV or closing the -door. -Make sure the stethoscope does not touch the patient's clothing or BP cuff. -Keep the stethoscope tubing still to avoid extraneous sound. -Ensure the chest piece is rotated to the diaphragm side. -Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) -Place the patient's feet in a tub of cool water with ice. -Apply a hyperthermia blanket as ordered. -Remove the patient's blankets. -Limit the patient's fluid intake. -Administer an antipyretic to the patient as ordered.
-Remove the patient's blankets. -Administer an antipyretic to the patient as ordered.
The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the following is inaccurate information that should not be included in the discussion? -Attach the restraint to the movable part of the bed frame. -When all side rails are raised, this may be considered a form of physical restraint. -Two fingers should be able to fit underneath the restraint. -Restraints provide a reliable method to prevent falls without serious complications.
-Restraints provide a reliable method to prevent falls without serious complications.
The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? -Notify the health care provider immediately. -Give the patient some water. -Allow the patient to rest. -Suction the airway as necessary.
-Suction the airway as necessary.
The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? -Reattempt using a different electronic BP machine. -Notify the health care provider of this change in patient condition. -Increase the patient's rate of intravenous (IV) fluids. -Take the patient's BP manually using a sphygmomanometer.
-Take the patient's BP manually using a sphygmomanometer.
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? -Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. -Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. -Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. -Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
-Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Which of the following vital signs are expected for the adult patient who has problems in oxygenation? -Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. -Temp 97.9° F (36.6 °C), P-80, R-18, BP 140/90, O2 sat 95%. -Temp 98.2° F (36.8 °C), P-64, R-16, BP 120/80, O2 sat 96%. -Temp 97.5° F (36.4 °C), P-76, R-20, BP 110/70, O2 sat 95%.
-Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%.
A healthy 30-year-old male arrives at the clinic for a physical. The nurse is responsible for collecting his vital signs. Which of these can be delegated to NAP? (Select all that apply.) -Temperature. -Pulse. -Respiration. -BP. -Pulse oximetry.
-Temperature. -Pulse. -Respiration. -BP. -Pulse oximetry.
A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? -Temporal artery -Tympanic -Chemical dot -Rectal electronic
-Temporal artery
Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) -The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. -The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. -The NAP waits until a tone sounds to read the tympanic thermometer. -The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. -The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.
-The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. -The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use.
The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) -The NAP is assessing for a pulse on the ulnar side of the wrist. -The NAP is pressing down too hard on the patient's radial site. -The NAP is assessing for a pulse on the thumb side of the wrist. -The NAP failed to auscultate the patient's wrist with a stethoscope. -The patient was previously reported to have a full, bounding pulse. -The NAP assessed the patient's BP before taking the patient's pulse.
-The NAP is assessing for a pulse on the ulnar side of the wrist. -The NAP is pressing down too hard on the patient's radial site.
Identify why a child's respirations might be shallow. -The child is in acute pain. -The child was running around in the waiting room with her sibling before her name was called. -The child's parents are smokers and the lungs are negatively affected by secondhand smoke. -The child is anxious about seeing the doctor.
-The child is in acute pain.
. The patient's BP reading is 150/80 mmHg. For this patient, 80 is representative of: (Select all that apply.) -The systolic pressure. -The diastolic pressure. -The ventricles during contraction. -The ventricles during relaxation. -The pulse deficit. -The pulse pressure.
-The diastolic pressure. -The ventricles during relaxation.
It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? -The patient has a temperature of 99.0°F when assessed rectally. -The patient has been NPO since midnight before the surgery. -The patient complains of pain at a 9 on a 0-10 pain scale. -The body is compensating for the cool environment of the surgical suite.
-The patient complains of pain at a 9 on a 0-10 pain scale.
A teen has come to the health care provider's office because he does not feel well after football practice. His temperature is 102°F (38.9°C). The nurse may conclude which of the following regarding this temperature reading? -This is a normal temperature for a person his age. -This is a low temperature for a person his age. -This is a high temperature for a person his age. -The reading is likely due to drug or alcohol intake.
-This is a high temperature for a person his age.
Which of the following situations may affect a patient's vital signs? (Select all that apply.) -Time of day. -Occupation. -Moving from lying to standing position. -Pain rated as a 7 on 0-10 pain scale. -Isolation precautions.
-Time of day. -Moving from lying to standing position. -Pain rated as a 7 on 0-10 pain scale.
The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? -To practice the technique of blood pressure measurement. -To determine if there is a difference in the readings between the two arms. -To verify the BP reading is 10 mm Hg higher in the dominant arm. -To assess for a pulse deficit and record this as a baseline measurement.
-To determine if there is a difference in the readings between the two arms.
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) -To determine whether the patient is "feeling funny" or "different". -To provide a set of vital signs to use for comparison during and after surgery. -To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. -To provide the patient with reassurance that he or she is being cared for by a competent staff. -To ensure the equipment is appropriately calibrated and functional.
-To provide a set of vital signs to use for comparison during and after surgery. -To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention.
Which of the following can be delegated? (Select all that apply.) -Transfer from bed to chair. -Determining a dependent patient's risk for aspiration. -Completing a fall risk assessment tool. -Applying restraints. -Moving a patient with an acute spinal cord injury up in bed.
-Transfer from bed to chair. -Applying restraints.
The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action(s) should the nurse take? (Select all that apply.) -None should be taken because this is a normal value. -Verify the reading by taking the patient's pulse oximetry. -Assist the patient to a high-Fowler's position. -Assist the patient to a fully supine position. -Be prepared to administer oxygen. -Perform a cardiopulmonary assessment. -Notify the health care provider.
-Verify the reading by taking the patient's pulse oximetry. -Assist the patient to a high-Fowler's position. -Be prepared to administer oxygen. -Perform a cardiopulmonary assessment. -Notify the health care provider.
Which of the following may increase both rate and depth of respiration? (Select all that apply.) -Walking 1 mile briskly. -Having a pain level rating at 7 on a scale of 0-10. -Feeling anxious when taking a test. -Smoking a cigarette. -Taking an opioid to relieve pain. -Having an addiction problem with amphetamines/cocaine. -Using a bronchodilator prior to exercise. -Incurring a head injury from a motor vehicle accident.
-Walking 1 mile briskly. -Feeling anxious when taking a test. -Having an addiction problem with amphetamines/cocaine.
The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? -When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. -When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. -When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. -After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.
-When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two.
For which patient would a tympanic thermometer be the preferred thermometer to use? -A marathon runner who developed weakness during the race. -A newborn that requires continuous temperature monitoring. -A pediatric patient who had tubes surgically placed in the ears. -A tachypneic patient who is receiving oxygen by nasal cannula.
A tachypneic patient who is receiving oxygen by nasal cannula.
A) 1-day-old newborn B) 3-year-old child C) 84-year-old female D) 18-year-old female 1) T-97.4° F, (36.3°C), P-144, R-58, BP 40 2) T-98.6° F, (37°C), P-60, R-16, BP 116/74 3) T-96.8° F, (36°C), P-98, R-20, BP 120/80 4) T-98.9° F, (37.1°C), P-110, R-20, BP 100/65
A) 1 B) 4 C) 3 D) 2
Match the animation to the description. Roll over each waveform to hear the breathing samples. A) Irregular rate and depth, characterized by alternating periods of apnea and hyperventilation. B) Rate is regular but greater than 20 breaths per minute C) Rate is regular but less than 12 breaths per minute. D) Rapid, deep regular respiration, found in diabetic ketoacidosis. (bradypnea, Cheyne-Stokes, Kussmaul, tachypnea)
A) Cheyne-Stokes B) Tachypnea C) Bradypnea D) Kussmaul
Which person would be expected to have the lowest body temperature? -A 16-year-old who ran 1 mile. -An 80-year-old who walked half a mile. -A toddler who is febrile. -A child playing softball.
An 80-year-old who walked half a mile.
