Ch. 30 Vital Signs
30. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a.Ulnar site b.Radial site c.Brachial site d.Femoral site
C. Brachial site 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
A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a.Patient's temperature is 113° F (45° C) with hot, dry skin. b.Patient's blood pressure sitting is 130/60 and 110/40 standing. c.Patient's pulse is 110 beats/min. d.Patient's temperature is 93.2° F (34° C). e.Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia
1. D. Patients temp is 93.2 F (34 C) 2.E. Patient's blood pressure went from 126/76 to 90/50. 3.A. Patient's temperature is 113° F (45° C) with hot, dry skin. 4.B. Patient's blood pressure sitting is 130/60 and 110/40 standing. 5.C. Patient's pulse is 110 beats/min.
27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a.This is normal for an infant. b.This is too fast for an infant. c.This is too slow for an infant. d.This is not a rate for an infant but for a toddler.
A. This is normal for an infant Infant normal pulse rate: 120 to 160 beats/min Toddler normal pulse rate: 90 and 140 beats/min
39. After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? a.Temperatures vary depending on the route used. b.Temperatures are readings of core measurements. c.Rectal temperatures are cooler than when taken orally. d.Axillary temperatures are higher than oral temperatures.
A. Temperatures vary depending on the route used -Rectal: 0.5° C (0.9° F) higher than oral -Axillary: 0.5° C (0.9° F) lower than oral -There are core temperature readings and body surface readings.
31. The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a.30 to 60 b.22 to 28 c.16 to 20 d.10 to 15
A. 30 to 60 Respiratory rate range: -Newborn=30 to 60 bpm -Infant (6 months)= 30 and 50 bpm -Toddler's= 25 to 32 bpm -Child= 20 to 30 bpm -Adolescent= 16 to 20 bpm -Adult= 12 to 20 times a minute.
38. The health care provider prescription reads "Metoprolol (Lopressor) 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. Which action should the nurse take? a.Documents that the medication was not given because of low blood pressure b.Does not inform the health care provider that the medication was held c.Does not tell the patient what the blood pressure is d.Documents only what the blood pressure was.
A. Documents that the medication was not given because of 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 BP value and the need for periodic reassessment of the BP -Documenting the BP 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
3. The nurse is assessing the patient and 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 findings will the nurse consider to be risk factors? (Select all that apply.) a.Obesity b.Cigarette smoking c.Recent weight loss d.Heavy alcohol intake e.Regular exercise sessions
A. Obesity B. Cigarette smoking D. Heavy alcohol intake Decrease risk: -Weight loss -Regular exercise
9. The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a.Place the patient on oxygen. b.Encourage the patient to cough. c.Restrict the patient's fluid intake. d.Increase the patient's metabolic rate.
A. Place the patient on oxygen Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. -Myocardial hypoxia produces angina. -Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. -Increasing the metabolic rate further would not be advisable. -Coughing will increase muscular activity, which will increase fever.
15. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a.Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b.Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist. c.Place the thumb over the groove along the little finger side of the patient's wrist. d.Place the thumb over the groove along the thumb side of the patient's wrist.
A. Place the tips of the first two fingers over the groove along the thumb side of the patients wrist
6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a.Wait 30 minutes and recheck the patient's temperature. b.Assume that the patient has an infection and order blood cultures. c.Encourage the patient to move around to increase muscular activity. d.Be aware that temperatures this high are harmful and affect patient safety.
A. Wait 30 minutes and recheck the patients temperature A fever is usually 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. -Nurses should base actions on knowledge, not on assumptions. -Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature.
23. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? a.Red blood cell count of 5.0 million/mm3 b.Hemoglobin level of 8.0 g/100 mL c.Hematocrit level of 45% d.Pulse oximetry of 95%
ANS: B The concentration of hemoglobin reflects the patient's capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. -Normal hemoglobin levels range from 14-18 g/100 mL (males) 12-16 g/100 mL (females)
17. The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a.60 b.80 c.140 d.200
ANS: B The difference between the systolic pressure and the diastolic pressure is the pulse pressure. (140 − 60 = 80)
13. The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse? a.Radial b.Brachial c.Femoral d.Popliteal
ANS: 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 difficult to palpate accurately.
14. The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a.Radial b.Apical c.Carotid d.Brachial
ANS: C. 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 the lower arm. -The apical pulse is used to auscultate the apical area.
12. The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a.Oral b.Axillary c.Tympanic d.Temporal
ANS: C. Tympanic -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.
20. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a.35 mm Hg b.40 mm Hg c.45 mm Hg d.50 mm Hg
ANS: D. 50 mmHg Normal capnography results are 35-45 mm Hg.
10. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a.Using appropriate route and device b.Assessing changes in body temperature c.Being aware of the usual values for the patient d.Obtaining temperature measurement at ordered frequency
B. Assessing changes in body temperature The nurse is responsible for assessing changes in body temperature. -The NAP can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient.
37. A nurse is caring for a group of patients. Which patient will the nurse see first? a.A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken b.A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 c.A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d.An 87-year-old male suspected of hypothermia whose temperature is below normal
B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. -Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. -A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. -A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see.
2. The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a.O2 saturations (SaO2) > 70% b.Carbon monoxide inhalation c.Hypothermic fingers d.Intravascular dyes e.Nail polish f.Jaundice
B. Carbon monoxide inhalation C. Hypothermic fingers D. Intravascular dyes E. Nail polish F. Jaundice Inaccurate pulse oximetry readings can be caused by: -outside light sources -carbon monoxide (smoke inhalation/poisoning) -patient motion -jaundice -intravascular dyes (methylene blue) -nail polish -artificial nails -metal studs -dark skin SpO2 is a reliable estimate: over 70%.
3. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? 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 because of the direct contact.
32. The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a.Secure the sensor to the toddler's earlobe. b.Determine whether the toddler has a latex allergy. c.Place the sensor on the bridge of the toddler's nose. d.Overlook variations between an oximeter pulse rate and the toddler's pulse rate.
B. Determine whether the toddler has a 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.
29. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a.It is not affected by skin moisture. b.It has no risk of injury to patient or nurse. c.It reflects rapid changes in radiant temperature. d.It is accurate even when the forehead is covered with hair.
B. It has no risk of injury to patient or nurse The temporal artery thermometer: -premature infants -newborns -children (there is no risk of injury to the patient or nurse) Temporal artery temperature: -noninvasive measure of core temperature -inaccurate with head covering/hair on the forehead -affected by skin moisture (diaphoresis, sweating) -provides very rapid measurement -reflects rapid changes in core temperature
36. The nurse is caring for a patient who reports 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.Apply more pressure to the radial artery to feel pulse. b.Perform an apical/radial pulse assessment. c.Call the health care provider immediately. d.Obtain arterial blood gases.
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 health care provider. The radial pulse is more accurately assessed with moderate pressure. -Too much pressure occludes the pulse and impairs blood flow -Arterial blood gases is a laboratory test that measures blood pH and oxygenation status (if respirations were abnormal or if pulse oximetry severely low)
22. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a.Attach a finger probe to the patient's index finger. b.Place a nonadhesive sensor on the patient's earlobe. 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 patients earlobe A nonadhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. -Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. -Do not attach probe to finger, ear, forehead, 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 the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates.
28. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a.The patient has hyperthermia. b.The patient has a normal temperature. c.The patient is suffering from hypothermia. d.The patient is demonstrating increased metabolism.
B. The patient has a normal temperature Older adult average body temp: Approximately 35°-36.1° C (95° to 97° F) Older adults have: -poor vasomotor control -reduced amounts of subcutaneous tissue -reduced sweat gland activity -reduced metabolism --END RESULT is lowered body temperature.
7. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a.Stethoscope b.Thermometer c.Blood pressure cuff d.Sphygmomanometer
B. Thermometer Pyrexia (fever) occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. -A sphygmomanometer is used to determine blood pressure
1. A nurse is working in the intensive care unit and must obtain CORE temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a.Rectal b.Tympanic c.Esophagus d.Temporal artery e.Pulmonary artery
B. Tympanic C. Esophagus E. Pulmonary artery Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a CORE temperature. Temporal artery measurements detect the temperature of cutaneous blood flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.
19. The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a.Allow the patient to breathe into a paper bag. b.Use oxygen cautiously in this patient. c.Administer high levels of oxygen. d.Give CO2 via mask.
B. Use oxygen cautiously in this patient Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. -Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. -Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or "rebreathed" with a paper bag.
35. 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 blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a.You can apply the cuff in any manner. b.You will need to recalibrate the machine. c.You can move your arm during the reading. d.You will need to use a stethoscope properly.
B. You will need to recalibrate the machine 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. -The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that DO NOT require the use of a stethoscope -The cuff will need to be applied CORRECTLY, and the patient's arm needs to BE STILL during the reading.
24. A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a.98/50 in a 7-year-old child b.115/70 in an infant c.120/80 in a middle-aged adult d.146/90 in an older adult
C. 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. 98/50 is normal for a child 115/70 can be normal for an infant.
40. When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a.68 b.76 c.138/62 d.138/70
C. 138/62
34. A nurse is caring for a group of patients. Which patient will the nurse see first? a.A crying infant with P-165 and R-54 b.A sleeping toddler with P-88 and R-23 c.A calm adolescent with P-95 and R-26 d.An exercising adult with P-108 and R-24
C. A calm adolescent with P-95 and R-26 Calm adolescent: P—60-90 and R—16-20 (Elevated... see first) -Infant: P—120-160 and R—30-50 (crying.. normal to be high) -Toddler: P—90-140 and R—25-32; (sleeping... slightly decreased is normal) -Adult: P—60-100 and R—12-20 (exercising... elevated is normal)
25. The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a.Non-Hispanic Caucasians b.European Americans c.African-Americans d.Asian Americans
C. African-Americans The incidence of hypertension is greater in: -diabetic patients -older adults -African-Americans -Hypertension in African-Americans > Hypertension in European Americans.
A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? 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.
18. The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a.Arterial blood gas b.Blood culture c.Hematocrit d.Potassium
C. Hematocrit The hematocrit (percentage of red blood cells in the blood) determines blood viscosity. -Blood cultures determine the causative agent of an infection. -Abnormal potassium levels can cause dysrhythmias. -Arterial blood gases determine acid-base balance or the pH levels of the blood.
8. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a.Hyperthermia and fever are the same thing. b.Hyperthermia is an upward shift in the set point. c.Hyperthermia occurs when the body cannot reduce heat production. d.Hyperthermia results from a reduction in thermoregulatory mechanisms.
C. Hyperthermia occurs when the body cannot reduce heat production -Hyperthermia results from an overload of the thermoregulatory mechanisms of the body.
16. The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? a.Inform the patient that she is counting respirations. b.Do not touch the patient until completed. c.Obtain without the patient knowing. d.Estimate respirations.
C. Obtain without the patient knowing
4. A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a.Apply just a diaper. b.Double the clothing. c.Place a cap on their heads. d.Increase room temperature to 90 degrees.
C. Place a cap on their head 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; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper.
26. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.
C. Smoking result in vasoconstriction, falsely elevating BP Smoking results in vasoconstriction (narrowing of blood vessels) BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. -Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement.
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure
C. Temperature Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control.
33. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a.Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b.Obtain the reading before the child has a chance to "settle down." c.Choose the cuff that says "Child" instead of "Infant." d.Explain the procedure to the child.
D. Explain the procedure to the child The child's cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children 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.
5. The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation.
D. Realize that this is a normal temperature variation Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period -usually lowest between 1:00 and 4:00 AM -maximum temperature at 4:00 PM -Unless the patient reports 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 health care provider to report a normal temperature variation.
41. The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? a.Ask the NAP retake the blood pressure. b.Instruct the NAP to assess the patient's other vital signs. c.Disregard the report and have it rechecked at the next scheduled time. d.Retake the blood pressure personally and assess the patient's condition.
D. Retake the BP personally and assess the patients condition The NAP should report abnormalities to the nurse, who should further assess the patient. -The NAP should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. -The report cannot be disregarded. Assessment must be done by the nurse.
21. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a.The patient has a fever. b.The patient has possible hemorrhage or bleeding. c.The patient has chronic obstructive pulmonary disease (COPD). d.The patient has calcium channel blockers or digitalis medication prescriptions.
D. The patient has calcium channel blockers or digitalis medication prescriptions 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.
11. The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature? a.Oral b.Rectal c.Axillary d.Tympanic
D. Tympanic 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 seizures. -Rectal temperatures require positioning and may increase patient agitation. -Axillary temperatures need long measurement times and continuous positioning. The patient's agitation state may not allow for long periods of attention.
4. The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a.Patients can actively participate in their treatment. b.Self-monitoring helps with compliance and treatment. c.The risk of obtaining an inaccurate reading is decreased. d.Blood pressures can be obtained if pulse rates become irregular. e.Patients can provide information about patterns to health care providers.
a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. e. Patients can provide information about patterns to health care providers. -Sometimes elevated BP is detected in persons previously unaware of a problem. -Persons with prehypertension provide information about the pattern of BP 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.
5. A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a.Apnea—no respirations b.Tachypnea—regular, rapid respirations c.Kussmaul's—abnormally deep, regular, fast respirations d.Hyperventilation—labored, increased in depth and rate respirations e.Cheyne-Stokes—abnormally slow and depressed ventilation respirations f.Biot's—irregular with alternating periods of apnea and hyperventilation respirations
a.Apnea—no respirations b.Tachypnea—regular, rapid respirations c.Kussmaul's—abnormally deep, regular, fast respirations Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Kussmaul's—Respirations are abnormally deep, regular, and increased in rate. Hyperventilation—Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Biot's—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea.