test 3 NUR 111 thermoregulation

The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's _____ pulse. a. Radial b. Brachial c. Posterior tibial d. Carotid

* d. carotid* The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to lower arm. The posterior tibial pulse is used to assess the status of circulation to the foot.

The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? 1. "Is there anything affecting her right arm?" 2. "Has she been experiencing any edema in that left arm?" 3. "How long has it been since she had her breast removed?" 4. "I'll wait until she's been medicated for pain before I take it."

*1. "Is there anything affecting her right arm?"* Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on that side; or the extremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer reflects an understanding that the right arm is the extremity of choice for monitoring this client's blood pressure.

The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) 1. "Low fat foods are your blood pressure's best friend." 2. "Have your triglyceride's checked on a regular basis." 3. "Ideal weight is ideal for keeping blood pressure under control." 4. "Nicotine is a no-no when attempting to control blood pressure." 5. "If they are prescribed, take your blood pressure medicine as suggested." 6. "Keep alcohol consumption down and your blood pressure will be down."

*1. "Low fat foods are your blood pressure's best friend." 2. "Have your triglyceride's checked on a regular basis." 3. "Ideal weight is ideal for keeping blood pressure under control." 4. "Nicotine is a no-no when attempting to control blood pressure." 6. "Keep alcohol consumption down and your blood pressure will be down."* Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Medication compliance, while important, is related to the management of hypertension, not prevention.

The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) 1. "The cuff cannot be too small or too big." 2. "Don't release the air out of the cuff to quickly." 3. "Keep the arm you are using at the level of the heart." 4. "If you are having difficulty, try taking it in the other arm." 5. "The stethoscope needs to be placed directly over a pulse point." 6. "Remember to pump up the cuff until you can no longer feel the pulse."

*1. "The cuff cannot be too small or too big." 2. "Don't release the air out of the cuff to quickly." 5. "The stethoscope needs to be placed directly over a pulse point." 6. "Remember to pump up the cuff until you can no longer feel the pulse."* Instruct the client or primary caregiver that if it is difficult to hear the pressure, the cuff is probably too loose, not big enough, or too narrow; the stethoscope is not over an arterial pulse; the cuff was deflated too quickly or too slowly; or the cuff was not inflated enough for systolic readings. The remaining options do not directly affect the actual hearing of the blood pressure.

The nurse has assessed a client's blood pressure (BP) using the left thigh because of bilateral upper arm casts. The client's precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: 1. 10-40 mm Hg higher systolic pressure than before the casting 2. 5-10 mm Hg higher reading in both systolic and diastolic pressures 3. Representative of the original baseline established before the casting 4. A slight decrease in the diastolic pressure when compared to precasting pressure

*1. 10-40 mm Hg higher systolic pressure than before the casting* Systolic pressure in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but the diastolic pressure is the same.

The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for alcohol detoxification 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old placed on antihypertensive medication therapy 2 months ago 4. An 80-year-old client whose systolic BP is routinely assessed in the high 80s

*1. A 25-year-old who was admitted for alcohol detoxification* Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and inability to cooperate are reasons to avoid using an electronic BP monitor. The answer reflects the client whose BP is most stable and best assessable via electronic BP monitor.

The nurse enters the room to measure the client's pulse rate. The nurse recognizes that the client's rate may be increased as a result of: 1. A febrile condition 2. Administration of digoxin 3. The client's athletic conditioning 4. Unrelieved severe postoperative pain

*1. A febrile condition* Fever and heat may increase a client's pulse rate. Digoxin is a negative chronotropic drug; it will decrease the client's pulse rate. A conditioned athlete who participates in long-term exercise will have a lower heart rate at rest. Unrelieved severe pain increases parasympathetic stimulation; decreasing the heart rate.

The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) 1. At the same time each day 2. On the same arm each time 3. In the same position each time 4. After the client has had a brief rest 5. After his blood pressure medication 6. Right before getting up in the morning

*1. At the same time each day 2. On the same arm each time 3. In the same position each time 4. After the client has had a brief rest* Instruct the client or primary caregiver to take BP at same time each day and after the client has had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure is taken. The other options are not necessary because they do not affect blood pressure readings.

An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

*1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min* These measurements are within the expected limits for an older client. An adult's average blood pressure is 120/80 mm Hg. The systolic pressure may increase with age, but the blood pressure should not exceed 140/90 mm Hg. The range for an adult's pulse is 60-100 beats/min. The expected respiratory rate is 16-25 breaths/min. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min; BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min; and BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min are not within the expected limits for a client of this age.

Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) 1. Possibility of decreased cardiac output 2. Potential for peripheral vascular disease 3. Existence of decreased red blood cell count 4. Uncooperative behavior related to senility 5. Inability to comprehend rationale for monitoring 6. vasoconstriction related to impaired heat regulation

*1. Possibility of decreased cardiac output 2. Potential for peripheral vascular disease 3. Existence of decreased red blood cell count 6. vasoconstriction related to impaired heat regulation* Identifying an acceptable pulse oximeter probe site is difficult with older adults because of the likelihood of peripheral vascular disease, decreased cardiac output, cold-induced vasoconstriction, and anemia. It would be inappropriate to assume that the process is made more difficult because of the remaining options because they are not seen in the majority of the elderly population.

The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1. Replacement of fluid and electrolytes 2. Initiation of oral antibiotic therapy 3. Application of hypothermia wraps 4. Alcohol sponge baths

*1. Replacement of fluid and electrolytes* The treatment of heat exhaustion includes transporting the client to a cooler environment and restoring fluid and electrolyte balance. Antibiotic therapy is not warranted. Hypothermia wraps are not used to treat heat exhaustion. Alcohol baths are not recommended.

A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse's most appropriate action is to: 1. Give the medication 2. Ask if the client is anxious 3. Check the client's dressing for bleeding 4. Recheck the client's vital signs in 30 minutes

*1. give the medication* The client's vital signs are consistent with the client being in pain. It would be safe and appropriate for the nurse to give the pain medication. Asking if the client is anxious is not the most appropriate action. The client is not demonstrating signs of shock (e.g., decreased blood pressure, increased pulse). The most appropriate action is for the nurse to administer pain medication. Rechecking would not be the most appropriate action. The nurse should medicate the client for pain.

The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: 1. Popliteal fossa behind the knee 2. Inner side of the ankle below the medial malleolus 3. Top of the foot between the extension tendons of the great toe 4. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine

*1. popliteal fossa behind the knee* The popliteal artery, palpable behind the knee in the popliteal space, is the site for auscultation when taking the blood pressure in the leg. The inner side of the ankle, top of the foot, and inguinal ligament are not the correct sites for assessment.

After measuring the client's vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should: 1. Retake the blood pressure 2. Retake the client's temperature 3. Report all of the findings immediately 4. Record the findings as within normal limits

*1. retake the blood pressure* The normal blood pressure reading is 120/80 mm Hg. This client's blood pressure is significantly higher at 180/100 mm Hg, and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions). The nurse should retake the blood pressure. The client's temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5° C. The nurse should repeat the blood pressure measurement to confirm the reading before reporting the findings. The blood pressure reading is not within normal limits. The pulse rate, respiratory rate, and temperature are within normal limits.

A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1. Wraps the cuff too loosely around the arm 2. Deflates the blood pressure cuff too quickly 3. Repeats the blood pressure assessment too soon 4. Presses the stethoscope too firmly in the antecubital fossa

*1. wraps the cuff too loosely around the arm* If the cuff is wrapped too loosely or unevenly around the arm, the effect on the blood pressure measurement may be a false high reading. A false low systolic and false high diastolic blood pressure reading may occur if the cuff is deflated too quickly. A false high systolic reading may be obtained if the blood pressure assessment is repeated too soon. A false low diastolic reading may be obtained if the stethoscope is applied too firmly against the antecubital fossa.

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. "I'll ask the clients what their blood pressure usually runs." 2. "I'll give you a list of all the readings I get before I chart them." 3. "I'll chart the results and let you know whose pressure is high." 4. "I'll recheck any pressure that seems higher than their normal."

*2. "I'll give you a list of all the readings I get before I chart them."* The nurse is responsible for assessing the impact of changes in blood pressure and so must be aware of each client's reading, not merely the values that the assistive personnel believes to be high. Asking the client to share what their BP is routinely and/or retaking a questionable reading is appropriate but not directly related to effective communication of the findings.

The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? 1. "As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy." 2. "If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever." 3. "I always wait a good 30 minutes after returning the older client back to bed before I count their pulse." 4. "I watch the elderly client's stomach and count the number of times it rises when I am counting respirations."

*2. "If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever."* RAT: The temperature of older adults is at the lower end of the normal temperature range, 36° to 36.8° C (96.9° to 98.3° F) orally and 36.6° to 37.2° C (98° to 99° F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult. The normal range for blood pressure is the same for older adults and younger people, while older adults depend more on accessory abdominal muscles during respiration than on weaker thoracic muscles, so observing the rise and fall of the abdomen would not be inappropriate. Once elevated, the pulse rate of an older adult takes longer to return to normal resting rate, so waiting 30 minutes would not be inappropriate.

The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) 1. "Take frequent breaks to rest out of the sun." 2. "The greater the humidity, the greater the hazard." 3. "Wear clothing that will absorb the perspiration." 4. "The higher the temperature, the higher the risk." 5. "The more fluids you drink, the fewer chances you take." 6. "Pay attention to pacing yourself when it's hot and muggy."

*2. "The greater the humidity, the greater the hazard." 4. "The higher the temperature, the higher the risk." 5. "The more fluids you drink, the fewer chances you take." 6. "Pay attention to pacing yourself when it's hot and muggy."* Teach clients risk factors for heatstroke: strenuous exercise in hot, humid weather; tight-fitting clothing in hot environments; exercising in poorly ventilated areas; sudden exposures to hot climates; poor fluid intake before, during, and after exercise. When paying close attention to avoiding risk factors for heatstroke, the remaining options are not required.

The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1. "Slowly deflate the pressure from the cuff." 2. "Wrap the cuff snuggly around the client's arm." 3. "Always support the client's arm at the level of the heart." 4. "Be sure that the cuff is wide enough for the client's arm." 5. "Allow the arm to rest before repeating the blood pressure." 6. "Make sure your stethoscope is fitted in your ears appropriately."

*2. "Wrap the cuff snuggly around the client's arm." 3. "Always support the client's arm at the level of the heart." 4. "Be sure that the cuff is wide enough for the client's arm." 5. "Allow the arm to rest before repeating the blood pressure."* Using a bladder or cuff that is too narrow or too short, wrapping the cuff too loosely or unevenly, resting the arm below heart level, and repeating assessments too quickly all contribute to a falsely high systolic reading. The rapid deflation of the cuff and an ill-fitted stethoscope will likely result in a falsely low systolic reading.

While the nurse is taking the client's blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4.118/80 mm Hg

*2. 130/84 mm Hg* The diagnosis of prehypertension in adults is made when an average of two or more diastolic readings on at least two subsequent visits is between 80 and 89 mm Hg or when the average of multiple systolic blood pressures on two or more subsequent visits is between 120 and 139 mm Hg. Hypertension is noted with diastolic readings greater than 90 mm Hg and systolic readings greater than 140 mm Hg. According to the newest guidelines, this client's blood pressure reading (130/84 mm Hg) would fall into the pre-hypertension category. Normal is 120/80 mm Hg; this is a normal blood pressure reading.

The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? 1. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely 2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate 3. A 75-year-old who is prescribed medication for Crohn's disease and who is sitting outdoors watching her granddaughter run the marathon 4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

*2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate* Clients at risk include those who are very young or very old and those who have cardiovascular disease, hypothyroidism, diabetes, or alcoholism. Also at risk are those who take medications that decrease the body's ability to lose heat (e.g., phenothiazines, anticholinergics, diuretics, amphetamines, and beta-adrenergic receptor antagonists) and those who exercise or work strenuously (e.g., athletes, construction workers, and farmers). While all the options represent risk factors, the degree of exercise, medical history, and age are greatest for the 16-year-old client with diabetes.

The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for depression and anxiety 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old prescribed antihypertensive medication 6 weeks ago 4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s

*2. A 69-year-old diagnosed with Parkinson's disease 5 years ago* Blood pressure less than 90 mm Hg systolic, irregular heart rate, peripheral vascular obstruction (e.g., clots, narrowed vessels), shivering, seizures, excessive tremors, and the inability to cooperate are reasons to avoid using an electronic BP monitor. The client's Parkinson's disease causes tremors, so a manual cuff should be used when assessing this client's BP.

A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: 1. The placement of the sensor on the extremity 2. A diagnosis of peripheral vascular disease 3. A reduced amount of artificial light in the room 4. The increased ambient temperature of the client's room

*2. A diagnosis of peripheral vascular disease* Peripheral vascular disease can reduce pulse volume, which may affect the pulse oximetry reading. The sensor should be placed on an extremity site (such as an earlobe or digit) with adequate local circulation and the site should be free of moisture. Reduced light in the room will not affect the oximetry reading. Outside light sources can interfere with the oximeter's ability to process reflected light. An increased temperature of the room will not affect the oximetry reading. If the room was very cold, the client's peripheral blood flow may decrease, affecting the oximetry reading.

Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds 2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds 3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds 4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds

*2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds* Determine most appropriate client-specific site (e.g., finger, earlobe) for sensor probe placement by measuring capillary refill. If capillary refill is greater than 3 seconds, select an alternate site. Sites should be free of moisture and tremors, and the nail should be free of polish (no artificial nails).

An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: 1. Take sips of brandy 2. Drink a bowl of warm soup 3. Drink a cup of very hot coffee 4. Run the affected extremities under hot water

*2. Drink a bowl of warm soup* A conscious client benefits from drinking hot liquids such as soup. Alcohol should be avoided. Caffeinated fluids should be avoided. Extremities should be warmed gradually. Tissue damage could occur if placed under hot water. The entire body should be warmed, such as by putting heating pads next to the head and neck that lose heat the quickest.

The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1. T = 37.4° C 2. P = 110 beats/min 3. R = 20 breaths/min 4. BP = 120/76 mm Hg

*2. P=110 beats/min* The expected pulse range for an adult is 60-100 beats/min. This client's pulse is elevated at 110 beats/min. This client's temperature is within the normal range of 36° to 38° C for an adult. This client's respiratory rate is within the normal range of 12-20 breaths/min for an adult. This client's blood pressure reading is within the normal range of 120/80 mm Hg for an adult.

The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1. Reflect a normal variation 2. Should be reported to the client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems

*2. Should be reported to the client's health care provider* During the initial assessment, obtain and record the blood pressure in both arms. Normally there is a difference of 5 to 10 mm Hg between the arms (Lane and others, 2002). In subsequent assessments, measure the blood pressure in the arm with the higher pressure. Pressure differences greater than 10 mm Hg indicate vascular problems and are reported to the health care provider or nurse in charge. Reporting the assessment findings is the most appropriate outcome.

The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? 1. The 75-year-old who has forgot where the car is parked 2. The 16-year-old volunteer whose skin appears sunburned but dry 3. The 34-year-old who finished the race and is reporting leg cramps 4. The 55-year-old observer who complains of nausea and being thirsty

*2. The 16-year-old volunteer whose skin appears sunburned but dry* Signs and symptoms of heatstroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Vital signs reveal a body temperature sometimes as high as 45° C (113° F) with an increase in heart rate and lowering of blood pressure. The most important sign of heatstroke is hot, dry skin. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. If the condition progresses, the client with heatstroke becomes unconscious with fixed, unreactive pupils. Permanent neurological damage occurs unless cooling measures are rapidly started.

The nurse is assessing an elderly client's blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the client's pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: 1. The difference between the monitoring equipment being used 2. The client may be experiencing mild anxiety regarding the check-up 3. The effects of aging on the client's ability to hear the first Korotkoff sound 4. The client is not inflating the cuff sufficiently to detect the systolic pressure

*2. The client may be experiencing mild anxiety regarding the check-up* Blood pressure measurements taken at the client's place of employment or in a health care provider's office are higher than those taken at the client's home. The remaining options may be a factor but they are not the most likely.

The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal

*2. apical* The brachial or apical pulse is the best site for assessing an infant's or young child's pulse because other peripheral pulses are deep and difficult to palpate accurately. The radial pulse is not the best site for assessing a 2-year-old's pulse. The femoral pulse is not the best site for assessing a 2-year-old's pulse. The pedal pulse is not the best site for assessing a 2-year-old's pulse.

The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1. Diaphoresis 2. Confusion 3. Temperature of 36° C 4. Decreased heart rate

*2. confusion* Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction. A normal temperature is 36° to 38° C. With heatstroke the client's body temperature may reach as high as 45°C. The heart rate is increased with heatstroke, not decreased.

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? 1. "I'll give you a list of all the readings after I chart them." 2. "May I ask the clients what their blood pressure usually runs?" 3. "I'll chart the results and let you know whose pressure is running high." 4. "Do you want me to take the readings before they get their medications?"

*3. "I'll chart the results and let you know whose pressure is running high."* The nurse is responsible for assessing the impact of changes in blood pressure and so must be promptly made aware of each client's reading, not merely the values that the assistive personnel believes to be high. The questions asked may reflect a need for further instruction, but the issues are not as critical as the need to report all readings for the nurse to evaluate.

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? 1. "Are all the clients cooperative enough to take the temperatures orally?" 2. "Do you want me to take the temperature tympanically on everyone?" 3. "I'll wait until breakfast is over so I won't distract them from eating." 4. "I'll chart the results and let you know whose temperature is running high."

*3. "I'll wait until breakfast is over so I won't distract them from eating."* When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are "running high."

When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1. Hold the thermometer at the bulb end 2. Cleanse the thermometer in hot water 3. Assess the thermometer for 5 minutes 4. Allow the child to hold the thermometer

*3. Assess the thermometer for 5 minutes* When assessing a client's axillary temperature with a glass thermometer, the thermometer should be left in place for 3 to 5 minutes. The thermometer should be held at the opposite end of the bulb. The thermometer should be covered with a plastic sheath when in use and after used the plastic sheath is discarded. If the thermometer requires cleaning, the nurse should not use hot water, as it could cause the thermometer to break. The parent should hold the thermometer, not the child. A 1 1/2-year-old client may drop the thermometer, creating a mercury spill.

The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1. Oral site 2. Rectal site 3. Axillary site 4. Tympanic site

*3. Axillary site* The axillary site can be used with newborns and uncooperative clients. The oral site should not be used with infants. The rectal site should not be used for routine vital signs in newborns. The tympanic site is questioned as being accurate in newborns.

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1. Review the client's chart for his last blood pressure reading. 2. Ask the client what his typical blood pressure reading is when taken manually. 3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. 4. Take the client's blood pressure both sitting and standing and use the higher reading.

*3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated.* The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. Palpation of the radial artery helps to determine how high to inflate the cuff. The examiner inflates the cuff 30 mm Hg above the pressure at which the radial pulse was palpated. Taking the blood pressure in various positions will not help eliminate the possible loss of auditory sound between the systolic and diastolic sounds. While asking the client and/or reviewing the chart may provide information concerning the client's pressure, these options are not the recommended method for minimizing the effect of the auditory gap on the assessment process.

The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg 3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg

*3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg* These are expected findings of a 10-year-old client. The normal pulse range for a 10-year-old is 75-100 beats/min; the normal respiratory rate is 20-30 breaths/min. The expected blood pressure range for a 7-year-old is 87-117/48-64 mm Hg; children who are larger (e.g., heavier and/or taller) have higher blood pressures. The average blood pressure for a 10-year-old is 110/65 mm Hg mm Hg. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg; P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg; and P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg are not expected values of a 10-year-old client.

A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and "feels uncomfortable." The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client's four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress

*3. Restrict oral fluid consumption* Wrapping the client's extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the client's axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided.

The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: 1. A constant body temperature above 100.4° F with little fluctuation 2. Spikes that are interspersed with normal temperatures within 24 hours 3. Spikes and falls in temperature, but temperature does not return to the normal limits 4. Periods of febrile episodes interspersed with normal body temperatures

*3. Spikes and falls in temperature, but temperature does not return to the normal limits* A remittent fever spikes and falls without a return to normal temperature levels. A sustained fever is a constant body temperature continuously above 38° C (100.4° F) that demonstrates little fluctuation. An intermittent fever has fever spikes interspersed with usual temperature levels. Temperature returns to acceptable levels at least once in 24 hours. A relapsing fever has periods of febrile episodes interspersed with acceptable temperature values.

A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, "I feel dizzy." The nurse should: 1. Go for help 2. Take the client's blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths

*3. assist the client into a sitting position* The nurse's primary concern should be the patient's safety and preventing an accidental fall. If the client just got up from bed and is complaining of dizziness, the client may be experiencing orthostatic hypotension. The nurse should first assist the client to sit down before performing any other assessment. The nurse should not leave the client and go for help. The nurse should assist the client to a sitting position. If help is required, the nurse can then put on the client's call light. The nurse may take the client's blood pressure after assisting the client to a sitting position to prevent the client from falling. The nurse should first assist the client to sit down to prevent the client from falling accidentally. The nurse may then assess the client. If the nurse finds during the assessment that the client's pulse oximetry is low, the nurse may instruct the client to take deep breaths.

The client appears to be breathing faster than before. The nurse should: 1. Ask the client if he has felt stressful 2. Have the client lay down on the bed 3. Count the client's rate of respirations 4. Palpate the client's own radial pulse

*3. count the clients rate of respirations* The first action the nurse should take is to assess the client's respiratory rate. The nurse can then determine if it is within normal limits and will be able to compare it to the previous measurement to determine if the client is breathing faster than before. Stress may increase an individual's respiratory rate. The nurse should first make the objective measurement of the client's rate. Having the client lay down may decrease a client's respiratory rate, but the nurse should first assess the client before implementing any nursing measures. The nurse should count the respiratory rate. Based on these findings the nurse may or may not need to take the client's pulse. Assessing the pulse will not verify if the client is breathing faster.

The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: 1. Second to third intercostal space 2. Third to fourth intercostal space 3. Fourth to fifth intercostal space 4.Fifth to sixth intercostal space

*3. fourth or fifth intercostal space* An apical pulse should be assessed at the client's PMI. The PMI is located at the fourth to fifth intercostal space at the left midclavicular line. Second to third intercostals space is not the correct placement for auscultating a client's apical pulse. The PMI is higher and more medial in children under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child. Fifth to sixth is not the correct placement for auscultating a client's apical pulse.

Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: 1. Biot's respirations 2. Kussmaul's respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations

*4. Cheyne-Stokes respirations* Cheyne-Stokes respirations are characterized by an irregular respiratory rate with alternating periods of apnea and hyperventilation. The respiratory cycle begins with slow, shallow breaths that gradually increase to an abnormal rate and depth. The pattern then reverses, breathing slows and becomes shallow, and the pattern climaxes in apnea before respiration resumes. Biot's respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea. Kussmaul's respirations are abnormally deep, regular, and increased in rate. Hyperpneic respirations are labored, increased in depth, and increased in rate (>20 breaths/min); they normally occur during exercise.

The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1. 10 to 40 mm Hg higher than in the brachial artery 2. 20 to 30 mm Hg lower than in the brachial artery 3. 40 to 50 mm Hg higher than in the brachial artery 4. Essentially the same as that in the brachial artery

*4. Essentially the same as that in the brachial artery* When measuring the blood pressure in the legs, systolic pressure is usually higher by 10 to 40 mm Hg than that in the brachial artery, but the diastolic pressure is the same. The systolic pressure, not the diastolic pressure, is 10 to 40 mm Hg higher than that in the brachial artery. Measurements of 20 to 30 mm Hg lower and 40 to 50 mm Hg higher are not true statements.

The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of a. 140. b. 60. c. 80. d. 200.

*c. 80* The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 - 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1. Deflating the cuff at 2 mm Hg/second 2. Having the client sit down for the measurement 3. Using the same time each day for the measurement 4. Taking the blood pressure after the client comes back from a walk

*4. Taking the blood pressure after the client comes back from a walk* The client's blood pressure should not be measured after the client has exercised, smoked, or ingested caffeine. The client should wait 30 minutes before assessment of the blood pressure. The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day.

A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: 1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature

*4. Wait 20 minutes before assessing the oral temperature* The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the child's temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the child's actual body temperature. The nurse should wait 20 minutes and measure the child's oral temperature.

A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: 1. Heatstroke 2. Heat cramp 3. Hypothermia 4. Heat exhaustion

*4. heat exhaustion* The client is exhibiting signs of heat exhaustion (e.g., symptoms of fluid volume deficit). If the client were experiencing heatstroke, the client would have an increased pulse rate and would not be sweating. Muscle cramps are related to heatstroke. The client is not exhibiting signs consistent with heatstroke. The client is not exhibiting signs of hypothermia such as shivering, loss of memory, or cyanosis.

The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1. Retake the vital signs in 30 minutes 2. Continue with care as planned 3. Administer a stimulant 4. Notify the physician

*4. notify the physician* The nurse should notify the physician, as these are abnormal findings. The client's respirations are becoming dangerously low at 8 breaths/min (normal 12-20 breaths/min). The client's pulse rate is low at 54 beats/min (expected 60-100 beats/min), and the blood pressure should be =120/80 mm Hg, which it is at 110/68 mm Hg. The additional assessment findings are also not normal, and should be reported to the physician. The nurse should not wait another 30 minutes to retake vital signs. The present readings warrant notifying the physician. These are abnormal findings. The nurse should not continue with care as planned. The nurse should first notify the physician. Administering a stimulant would require a physician's order and may not be what the client requires. For example, the client may need a narcotic antagonist rather than a stimulant.

When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as a. Pyrexia. b. The plateau phase. c. The set point. d. Becoming afebrile.

*A. pyrexia* Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient's temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the physician immediately to report a possible infection. b. Realize that this is a normal temperature variation. c. Provide another blanket to conserve body temperature. d. Provide medication to lower the temperature further.

*B. Realize that this is a normal temperature variation.* Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation

The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient's temperature through the use of a. Radiation. b. Conduction. c. Convection. d. Evaporation

*B. conduction* Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should a. Call the physician and anticipate an order to treat the fever. b. Assume that the patient has an infection and order blood cultures. c. Wait an hour and recheck the patient's temperature. d. Be aware that temperatures this high are harmful and affect patient safety.

*C. Wait an hour and recheck the patient's temperature.* Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Mild temperature elevations enhance the body's immune system by stimulating white blood cell production. Usually, staff nurses do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

When focusing on temperature regulation of newborns and infants, the nurse understands that a. Temperatures are basically the same for infants and older adults. b. Infants have well-developed temperature-regulating mechanisms. c. The normal temperature range gradually increases as the person ages. d. Newborns need to wear a cap to prevent heat loss.

*D. Newborns need to wear a cap to prevent heat loss.* A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops as individuals approach older adulthood.

The nurse is caring for a newborn infant in the hospital nursery. She notices that the infant is breathing rapidly but is pink, warm, and dry. The nurse knows that the normal respiratory rate for a newborn is _____ breaths per minute. a. 30 to 60 b. 25 to 32 c. 16 to 19 d. 12 to 20

*a. 30 to 60* The acceptable respiratory rate range for a newborn is 30 to 60 breaths per minute. An infant (6 months) is expected to have a rate between 30 and 50 breaths per minute. A toddler's respiratory range is 25 to 32 breaths per minute. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 19 times a minute. An adult should breathe 12 to 20 times a minute.

Of the following patients, which one is the best candidate to have his temperature taken orally? a. A 27-year-old postoperative patient with an elevated temperature b. A teenage boy who has just returned from outside "for a smoke" c. An 87-year-old confused male suspected of hypothermia d. A 20-year-old male with a history of epilepsy

*a. A 27-year-old postoperative patient with an elevated temperature* An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

The posterior hypothalamus helps control temperature by a. Causing vasoconstriction. b. Shunting blood to the skin and extremities. c. Increasing sweat production. d. Causing vasodilation.

*a. Causing vasoconstriction.* If the posterior hypothalamus senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production.

The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values could account for the patient's symptoms? a. Hemoglobin level of 8.0 b. Hematocrit level of 45% c. Red blood cell count of 5.0 million/mm3 d. Pulse oximetry of 90%

*a. Hemoglobin level of 8.0* The concentration of hemoglobin reflects the patient's capacity to carry oxygen. Normal hemoglobin levels range from 10 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is a. Place the patient on oxygen. b. Restrict fluid intake. c. Increase patient activity. d. Increase patient's metabolic rate.

*a. Place the patient on oxygen.* During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable.

The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the thumb over the groove along the thumb side of the patient's wrist. c. Apply a very light touch so that the pulse is not obliterated. d. Apply very strong pressure to detect the pulse.

*a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.* Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow.

When recording the patient's respiratory status, what must be recorded? (Select all that apply.) a. Respiratory rate b. Character of respirations c. Amount of oxygen therapy d. Only normal findings e. Only in the graphic section

*a. Respiratory rate b. Character of respirations c. Amount of oxygen therapy* Record respiratory rate and character in nurses' notes or on vital sign flow sheet. Indicate type and amount of oxygen therapy if used during assessment. Document respiratory assessment after administration of specific therapies in narrative form in nurses' notes. The nurse should document normal and abnormal findings.

One benefit of using a stationary automatic blood pressure device is that the cuff a. Fits over clothing. b. Is extremely reliable. c. Is the method of choice for irregular heart rhythms. d. Is more reliable when pressure is less than 90 mm Hg systolic.

*a. fits over clothing* The cuff fits over clothing. However, the reliability of stationary machines is limited. Electronic blood pressure measurement is not recommended with irregular heart rates or when blood pressure is less than 90 mm Hg systolic.

The thickness or viscosity of the blood affects the ease with which blood flows through small vessels. The nurse examines what value, which might help determine the amount of blood viscosity? a. Hematocrit b. Cardiac output c. Arterial size d. Blood volume

*a. hematocrit* The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood pressure also depends on the cardiac output or volume pumped by the heart, but cardiac output does not affect viscosity. Arterial size helps to modify blood pressure. The smaller lumen of a vessel increases vascular resistance but does not affect viscosity. Blood volume also affects blood pressure, but it does not directly affect viscosity.

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. The nurse realizes that his rate is a. Normal for an infant. b. The proper rate for a toddler. c. Too slow for an infant. d. The same as that of a normal adult.

*a. normal for an infant* The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min. The normal rate for an adult is between 60 and 100 beats/min.

The nurse is assessing the patient and his family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol consumption e. Low blood cholesterol levels

*a. obesity, b. cigarette smoking, d. heavy alcohol consumption* Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Weight loss and low blood cholesterol levels are not risk factors for hypertension.

The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: 1. An alcohol and water bath 2. Ice packs to the axillae and groin 3. Tepid, plain water sponge down 4. Application of a cooling blanket

*application of a cooling blanket* Blankets cooled by circulating water delivered by motorized units increase conductive heat loss. Cooling blankets are used to reduce a fever. Bathing with an alcohol/water solution is not recommended because it may lead to shivering. Shivering is counterproductive and can increase energy expenditure up to 400%. Application of ice packs to the axillae and groin is no longer recommended because they may induce shivering (which is counterproductive and increases the client's energy expenditure), and because they have no advantage over antipyretic medications. Tepid sponge baths are no longer recommended because it may lead to shivering and is no more advantageous than administering antipyretics.

The incidence of hypertension is greater in which of the following? a. Non-Hispanic Caucasians b. African Americans c. Asian Americans d. Native Americans

*b. African Americans* The incidence of hypertension is greater in diabetic patients, older adults, and African Americans.

When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel? a. Temperature measurement b. Assessment of changes in body temperature c. Selection of appropriate route and device d. Consideration of factors that falsely raise temperature

*b. Assessment of changes in body temperature* The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors that falsely raise or lower temperature.

The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.) a. O2 saturations (SaO2) >70% b. Carbon monoxide inhalation c. Nail polish d. Hypothermia at the assessment site e. Intravascular dyes

*b. Carbon monoxide inhalation c. Nail polish d. Hypothermia at the assessment site e. Intravascular dyes* Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. Other factors include peripheral vascular disease (atherosclerosis), hypothermia at the assessment site, pharmacological vasoconstrictors (e.g., epinephrine), low cardiac output, hypotension, peripheral edema, and tight probes.

The nurse is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is a. Suffering from hypothermia. b. Expressing a normal temperature. c. Hyperthermic relative to his age. d. Demonstrating the increased metabolism that accompanies aging.

*b. Expressing a normal temperature.* The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature.

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take his blood pressure three times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. The nurse also instructs the patient that the a. Patient can apply the cuff in any manner he chooses because the machine is designed to be used by nonprofessionals. b. Machine requires frequent calibration to ensure accuracy. c. Cuff can be placed over clothing if necessary. d. Machine is accurate when blood pressures are low.

*b. Machine requires frequent calibration to ensure accuracy.* Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. Stationary blood pressure devices are often found in public places, and the cuff fits over clothing. The same is not true for portable devices. Electronic blood pressure measurement is not recommended when pressure is less than 90 mm Hg systolic.

While the nurse is assessing the patient's respirations, it is important for the patient to a. Be aware of the procedure being done. b. Not know that respirations are being assessed. c. Understand that respirations are estimated to save time. d. Not be touched until the entire process is finished.

*b. Not know that respirations are being assessed.* Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

The patient is being encouraged to purchase a portable automatic blood pressure device so he can monitor his own blood pressure at home. What are some of the benefits of this? (Select all that apply.) a. Blood pressures can be obtained if pulse rates become irregular. b. Patients can provide information about patterns to health care providers. c. Patients can actively participate in their treatment. d. Self-monitoring helps with compliance and treatment. e. The risk of obtaining an inaccurate reading is decreased.

*b. Patients can provide information about patterns to health care providers. c. Patients can actively participate in their treatment. d. Self-monitoring helps with compliance and treatment.* Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate.

The nurse is caring for a patient who complains of feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Call the physician immediately. b. Perform an apical/radial pulse assessment. c. Apply more pressure to the radial artery to assess the pulse. d. Use his thumb to detect the patient's pulse.

*b. Perform an apical/radial pulse assessment.* If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the physician. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Fingertips are the most sensitive parts of the hand to palpate arterial pulsations. The thumb has a pulsation of its own that interferes with accuracy.

The patient was found unresponsive in her apartment and is being brought to the emergency department. She has arm, hand, and leg edema, her temperature is 95.6° F, and her hands are cold secondary to her history of peripheral vascular disease. It is reported that she has a latex allergy. To quickly measure the patient's oxygen saturation, what should the nurse do? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's ear lobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on.

*b. Place a nonadhesive sensor on the patient's ear lobe.* Select ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach sensor to finger, ear, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place sensor on the same extremity as electronic blood pressure cuff because blood flow to finger will be temporarily interrupted when cuff inflates.

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. Why is this done? a. Temperatures are the same regardless of the route used. b. Temperatures vary depending on the route used. c. Temperatures are cooler when taken rectally than when taken orally. d. Axillary temperatures are higher than oral temperatures.

*b. Temperatures vary depending on the route used.* Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0° C (0.9° F) lower than oral temperatures.

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse's best option would be to take his temperature a. Orally. b. Tympanically. c. Rectally. d. By the axillary method.

*b. Tympanically.* The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning by the nurse. The patient's agitation state may not allow for long periods of attention.

The patient is being admitted to the emergency department with complaints of shortness of breath. The patient has had chronic lung disease for many years but still smokes. The nurse should a. Administer high levels of oxygen. b. Use oxygen cautiously in this patient. c. Place a paper bag over the patient's face to allow rebreathing of carbon dioxide. d. Administer CO2 via mask.

*b. Use oxygen cautiously in this patient.* Because low levels of arterial O2 provide the stimulus that allows the patient to breathe, administration of high oxygen levels will be fatal for patients with chronic lung disease. Oxygen must be used cautiously in these types of patients. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or "rebreathed."

The nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be the _____ artery. a. Radial b. Brachial c. Femoral d. Popliteal

*b. brachial* The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and are difficult to palpate accurately.

Which statement is true of the ovulation phase? a. Progesterone levels are below normal. b. Body temperature is below baseline levels. c. Body temperature is at previous baseline levels or higher. d. Intense body heat and sweating occur.

*c. Body temperature is at previous baseline levels or higher.* Progesterone levels rise and fall cyclically during the menstrual cycle. When progesterone levels are low, the body temperature is a few tenths of a degree below the baseline. The lower temperature persists until ovulation occurs. During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher. These temperature variations help to predict a woman's most fertile time to achieve pregnancy. Women who undergo menopause (cessation of menstruation) often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes).

The nurse is caring for a patient who has a pulse rate of 44. His blood pressure is within normal limits. In trying to determine the cause of the patient's low heart rate, the nurse would suspect a. That the patient would have a fever. b. Possible hemorrhage or bleeding. c. Calcium channel blockers or digitalis medications. d. Chronic obstructive pulmonary disease (COPD).

*c. Calcium channel blockers or digitalis medications.* Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate.

While attempting to obtain oxygen saturation readings on a toddler, what should the nurse do? a. Place the sensor on the earlobe. b. Place the sensor on the bridge of the nose. c. Determine whether the toddler has a tape allergy. d. Ignore any variation between the oximeter pulse rate and the patient's apical pulse rate.

*c. Determine whether the toddler has a tape allergy.* The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient's apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates.

The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication and a. Does not tell the patient what the blood pressure is. b. Documents only what the blood pressure was. c. Documents that the medication was not given owing to low blood pressure. d. Does not need to inform the health care provider that the medication was held.

*c. Documents that the medication was not given owing to low blood pressure.* The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.

The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should a. Have the nursing assistive person retake the blood pressure. b. Ignore the report and have it rechecked at the next scheduled time. c. Retake the blood pressure herself and assess the patient's condition. d. Have the nursing assistive person assess the patient's other vital signs.

*c. Retake the blood pressure herself and assess the patient's condition.* The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse.

Which artery is the most appropriate for assessing the pulse of a small child? a. Radial b. Femoral c. Brachial d. Ulnar

*c. brachial* the brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses are deep and difficult to palpate accurately.

2. Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement? a. Radiation b. Conduction c. Convection d. Evaporation

*c. convection* Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes? a. Oral b. Axillary c. Rectal d. Temporal

*c. rectal* The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

Of the following sites, which are used for obtaining a core temperature? (Select all that apply.) a. Oral b. Rectal c. Tympanic d. Axillary e. Pulmonary artery

*c. tympanic & e. pulmonary artery* Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

Of the following values, which value would be considered prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 140/90 in an older adult d. 120/80 in a middle-aged adult

*d. 120/80 in a middle-aged adult* An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel? a. Selecting appropriate route and device b. Obtaining temperature measurement at ordered frequency c. Being aware of the usual values for the patient d. Assessing changes in body temperature

*d. Assessing changes in body temperature* The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient's blood pressure? a. Neither caffeine nor smoking affects blood pressure. b. she needs to insist that the patient stop smoking for at least 3 hours. c. The nurse should have the patient perform mild exercises. d. Caffeine and smoking can cause false BP elevations.

*d. Caffeine and smoking can cause false BP elevations.* Smoking immediately increases BP, and this increase lasts up to 15 minutes. Caffeine increases BP for up to 3 hours. Both affect a patient's blood pressure. The patient should rest at least 5 minutes before BP is measured.

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Choose the cuff that says "Child" instead of "Infant." b. Obtain the reading before the child has a chance to "settle down." c. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. d. Explain to the child what the procedure will be.

*d. Explain to the child what the procedure will be.* Preparing the child for the blood pressure cuff's unusual sensation increases cooperation. Most children will understand the analogy of a "tight hug on your arm." Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An "Infant" cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

The nurse is caring for a patient who has an elevated temperature. The nurse understands that a. Fever and hyperthermia are the same thing. b. Hyperthermia occurs when the body cannot reduce heat loss. c. Hyperthermia is an upward shift in the set point. d. Hyperthermia occurs when the body cannot reduce heat production.

*d. Hyperthermia occurs when the body cannot reduce heat production.* Fever and hyperthermia are not the same things. An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia. Fever is an upward shift in the set point. Hyperthermia is not a shift in the set point.

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. Why is this preferable to methods used for adults? a. It is accurate even when the forehead is covered with hair. b. It is not affected by skin moisture. c. It reflects rapid changes in radiant temperature. d. There is no risk of injury to patient or nurse.

*d. There is no risk of injury to patient or nurse.* The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature.

The nurse is alert to which of the following factors that lowers the blood pressure? 1. Stress-producing anxiety 2. Heavy alcohol consumption 3. Cigarette, cigar, or pipe smoking 4. Prescribed diuretic administration

*prescribed diuretic administration* Diuretics lower blood pressure by reducing reabsorption of sodium and water by the kidneys, thus lowering circulating fluid volume. The effects of sympathetic nerve stimulation, such as with anxiety, increase blood pressure. Heavy alcohol consumption has been linked to hypertension. Cigarette smoking has been linked to hypertension.