ATI: Priority Setting, ATI 10: Clinical Judgement Process, ATI Quiz: Fundamentals 1, ATI VItal Signs Test, Vital Signs, Safety, ATI vital post test

A nurse and urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?

Assessment

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

Assessment

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery."

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after excessive as I get older."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP

"Using a cuff that is too small will result in an inaccurately high reading."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?"

Adverse effects of morphine

- Bladder distention. request Rx for urinary catheterization - Constipation teach ways to manage it - Orthostatic hypotension remind to change positions slowly

A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include.

1) select the site for obtaining the measurement 2) apply the sensor probe on the chosen site 3) confirm the pulse rate displayed o the oximeter by palpating the radial pulse 4) wait 15 seconds and observer the SaO2 percentage displayed on the pulse oximeter

A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administe analgesics to the child on a routine schedule throughout the day and night.

In what order should an RN perform the steps of the nursing process?

Assessment, analysis, planning, implementation, evaluation

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss?

Attempt to increase the client's self-motivation

A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?

Available resources, awareness of client status, support from other staff

A nurse is assessing a client who has cancer and is receiving morphine for pain management. Which of the following findings is the nurse's priority? A. Orthostatic hypotension B. Respiratory rate 10/min C. Absence of bowel movement for 5 days D. Bladder distention

B. Respiratory rate 10/min The nurse should identify that the respiratory rate of 10/min is the priority finding by using the airway, breathing, circulation approach to client care. A respiratory rate of 10/min is an indication of toxicity. The nurse should not administer the next dose of medication and should notify the provider immediately.

A nurse is preparing to apply a condom catheter a male client. Which of the following actions should the nurse take after performing hand hygiene and applying clean gloves? A. Provide perineal care to the client. B. Prepare the drainage bag and tubing. C. Check the condition of the penile shaft. D. Place a bath blanket over the client's upper torso.

C. Check the condition of the penile shaft. The first action the nurse should take when using the nursing process is assessment. To maintain safety and prevent injury to the client by taking the necessary precautions, the nurse should check the condition of the client's skin to determine a baseline. The nurse should then monitor the client's skin for redness, swelling, or lesions.

A nurse in the PACU is caring for a client who is postoperative following an abdominal hysterectomy. Which of the following actions should the nurse take first? A. Encourage the client to cough and deep breathe. B. Change the client's perineal pad. C. Place the client in a side-lying position. D. Monitor the client's urinary output.

C. Place the client in a side-lying position. The greatest risk to this client is injury from an obstructed airway; therefore, the first action the nurse should take is to place the client in a side-lying position to allow her tongue to fall to the side of her mouth, instead of having her tongue obstruct her airway.

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene

A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?

Clinical judgment

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors?

Complex clinical situations, ongoing client and family concerns

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?

Critical thinking is the foundation for clinical decision making

A nurse enters a client's room and sees the client lying next to the bed. Which of the following actions should the nurse take first? A. Complete an incident report. B. Notify the client's provider. C. Move the client back into bed. D. Obtain the client's vital signs.

D. Obtain the client's vital signs. The greatest risk to this client is injury from falling out of bed; therefore, the first action for the nurse to take is to obtain the client's vital signs to verify that the client is stable.

A nurse is assessing four clients. Which of the following clients should the nurses assess first? A client who has: A. COPD and has a respiratory rate of 23/min B. gastric cancer and reports nausea and vomiting C. rheumatoid arthritis and has joint swelling D. a chest tube and has asymmetrical chest movement

D. a chest tube and has asymmetrical chest movement When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax.

A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?

Delegation of the wrong task

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Discontinue the machine, and measure the blood pressure manually every 15 min.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?

Donate autologous blood before the surgery

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care

A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Evaluation

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?

Inference, creativity, inductive reasoning

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

Inspect, Auscultate, Percuss, Palpate

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?

Lock the wheels on the bed and stretcher

A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?

Planning

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes with her hands held higher than her elbows

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's

A nurse is reviewing vitals for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? a) an adult client who received medication for pan 30 min ago now has a RR of 18/min b) a school-age child who received two units of packed RBCs now has a BP of 76/54 mm Hg c) a toddler who received an antibiotic injection has a heart rate of 148/min while sleeping in their parent's arms

a) an adult client who received medication for pan 30 min ago now has a RR of 18/min

A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vitals should the nurse identify is outside the expected reference range and notify the provider? a) a client who has an apical pulse rate of 120/min b) a client who has a BP of 100/74 mm Hg c) a client who has an apical pulse rate of 84/min d) a client who has a BP of 110/68 mm Hg

a) a client who has an apical pulse rate of 120/min

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg d) an adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min

a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg

A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? a) apex of the heart b) right side of the sternum c) 4th intercostal space d) midclavicular line below right clavicle

a) apex of the heart

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take? a) encourage the client to change positions slowly b) restrict the client's oral intake of fluids c) encourage the client to take a short walk d) discontinue IV fluids

a) encourage the client to change positions slowly

A charge nurse is reviewing the expected reference ranges of BP in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? a) hypertension is diagnosed with two elevated measurements on two separate occasions b) successive BP measurements of 126 over 78 is classified as stage I hypertension c) stage II hypertension is diagnosed when the BP measurement is 132 over 86 d) a BP measurement of 176 over 102 is classified as hypertensive crisis

a) hypertension is diagnosed with two elevated measurements on two separate occasions

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? a) increase in BP b) increase in RR c) decrease in cardiac output d decrease in preload

a) increase in BP

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? a) instruct the client to bear down like they are having a bowel movement b) offer the client hot caffeinated tea to drink early in the morning c) hold the client's thyroid medication d) encourage the client to take a warm shower

a) instruct the client to bear down like they are having a bowel movement

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? Select all that apply a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine e) anticipate a prescription for a 1L fluid bolus

a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine

A nurse is planning care for a group of clients and is reviewing the recent vitals obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? a) 16 year old female; RR 18/min, SaO2 98% b) 8 year old male; RR 34/min, SaO2 97% c) 11 year old male; RR 28/min, 99% d) 3 year old female; RR 32/min, SaO2 96%

b) 8 year old male; RR 34/min, SaO2 97%

A nurse is discussing the physiology of BP. Which of the following information should the nurse include? a) Diastolic BP reflects the pressure exerted during contraction of the heart b) BP is measured and documented in mm Hg c) BP decreases when blood viscosity increases d) systolic BP reflects the pressure when the heart is relaxed

b) BP is measured and documented in mm Hg

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? a) a client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position b) a client has a radial pulse of +4 bilateral c) an older adult client has a tympanic temperature of 35.9 degrees c (96.6 degrees f) d) a newborn has a RR of 56/min while sleeping

b) a client has a radial pulse of +4 bilateral

A nurse is reviewing the vitals for a group of clients obtained by an AP. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? a) a school-age child who has an apical pulse of 78/min b) a young adult who has a radial pulse of 56/min c) an adolescent who has a radial pulse of 76/min d) an older adult with apical pulse of 62/min

b) a young adult who has a radial pulse of 56/min

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? a) anxiety can cause a decrease in RR b) body temperature is typically lower in olde adults c) caffeine can cause a temporary decrease in pulse rate in adolescents d) BP can slightly decrease immediately following the use of nicotine

b) body temperature is typically lower in older adults

A charge nurse is discussing a client's RR data with a newly licensed nurse. Which of the following statements should the nurse include? a) clients will exhibit an increase in their RR after using a bronchodilator b) count the RR for 1 min who have a respiratory infection c) expect clients who have a brainstem injury to exhibit rapid respirations d) clients who are experiencing acute pain will have slow, deep respirations

b) count the RR for 1 min who have a respiratory infection

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires a follow up by the nurse? a) eupnea b) dyspnea c) heart rate of 84/min d) Sao2 of 96%

b) dyspnea

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? a) oxygen saturation is determined by the amount of oxygen bound to WBCs b) oxygen saturation reflects the amount of oxygen being delivered to body tissues c) the expected reference range for oxygen saturation s 90% to 100% d) a capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement

b) oxygen saturation reflects the amount of oxygen being delivered to body tissues

A charge nurse is teaching a group of AP the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? a) record vital signs at the end of the shift b) recording vital signs provides critical information regarding a client's condition c) obtaining and documenting baseline vital signs is the responsibility of the AP d) it is not necessary to record electronic BP measurements

b) recording vital signs provides critical information regarding a client's condition

A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? a) the AP pulls the pinna up and back when obtaining a tympanic temperature b) the AP informs the client when they are counting the respirations c) the AP gently presses down with the pads of two or three fingers over the radial pulse site d) the AP selects a blood pressure cuff that is 40% the circumference of the client's arm

b) the AP informs the client when they are counting the respirations

A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene? a) adult male who has a RR of 18/min b) toddler who has a RR of 44/min c) newborn who has a RR of 56/min d) adolescent female who has a RR of 16/min

b) toddler who has a RR of 44/min

A charge nurse is evaluating a newly licensed nurse's documentation of vitals for several clients. Which of the following documentation should the charge nurse identify as being incomplete? a) radial pulse regular at 84/min b) respirations observed as even, nonlabored at 20/min with client in supine position c) BP 124/82 mm Hg lying in bed d) temporal temperature 36.9 degrees C (98.4 degrees F)

c) BP 124/82 mm Hg lying in bed

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? a) AV node b) left ventricle c) SA node d) right ventricle

c) SA node

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? a) pulse 52/min b) RR 24 c) SaO2 97% right index finger, room air d) BP 132/86 mm Hg

c) SaO2 97% right index finger, room air

A nurse is reviewing the vital signs fir four clients. The nurse should identify that which of the following clients has a vital sign outside of the reference range? a) a 52 year old client who has a fever due to a would infection and a pulse rate of 100/min b) a 76 year old client who reports moderate pain and has a RR of 20/min c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95% d) a 23 year old client who runs marathons and has a BP of 82/54 mm Hg

c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95%

A nurse is reviewing the recent vitals of a group of clients. Which of the following clients should the nurse see first? a) a 45 year old client who is post-op and has a BP of 130/82 b) a 28 year old client who runs marathons and has a HR of 54/min c) a 52 year old client who has an SaO2 of 92% d) a 78 year old client who has a temperature of 35.9 degrees c (96.6 degrees f)

c) a 52 year old client who has an SaO2 of 92%

A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? a) the first step in checking for checking orthostatic hypotension is obtaining a client's BP while they are standing b) an increase of 5 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension d) wait 5 minutes to check the client's BP after each position change

c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? a) an infant who has an apical pulse rate of 132/min b) a preschooler who has an apical pulse rate of 108/min c) a young adult who has an apical pulse rate of 104/min d) an older adult who has an apical pulse rate of 96/min

c) a young adult who has an apical pulse rate of 104/min

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? a) a 17 year old who has a RR of 16/min b) a young adult who has a pulse rate of 98/min c) an 11 year old who has a RR of 34/min d) an older adult who has a pulse rate of 62/min

c) an 11 year old who has a RR of 34/min

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make? a) instruct the client to increase exercise b) instruct the client to consume no more than four caffeinated beverages per day c) encourage the client to practice relaxation techniques each day d) encourage the client to engage in pattern paced breathing by panting

c) encourage the client to practice relaxation techniques each day

A nurse is assessing a three month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? a) count the number of beats heard in 15 seconds and multiply by 4 b) notify the provider if the apical pulse rate is greater than 110/min c) place the stethoscope over the 4th intercostal space to the left of the sternum d) auscultate the apical pulse for an S4 heart sound

c) place the stethoscope over the 4th intercostal space to the left of the sternum

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include? a) the body increases body temperature through the process known as vasodilation b) the body loses heat through shivering c) the body lowers body temperature through sweating d) the body generates heat through evaporation

c) the body lowers body temperature through sweating

A nurse is observing an AP who is obtaining BP reading from a client. Which of the following actions by the AP requires follow up by the nurse? a) the AP uses a cuff width that is 40% of the circumference of the client's arm b) he AP provides support for the client's arm while taking the BP c) the AP waits to take the client's BP 45 minutes after the client ambulates in the hallway d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second

d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second (Recommended rate is 2 mm Hg per second)

A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? a) "Convection is the loss of body heat when a client is in contact with a cooler surface." b) "Conduction is the loss of body heat when sweat dries from a client's skin." c) "Evaporation is the loss of body heat when a client is near a current of cool air." d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following should the nurse include? a) A client diagnosed with an elevated BP when the measurement is greater than 130/80 mm Hg b) A client us experiencing a hypertensive crisis when their BP is greater than 150/90 mm Hg c) A client who has a BP of 128/86 mm Hg has stage I hypertension d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension

d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension

A nurse is preparing an in-service about factors affecting RR for a group of APs. Which of the following information should the nurse include? a) anxiety can decrease a client's RR b) opioid analgesics can increase a client's RR c) pain can decrease a client's RR d) Fever can increase a client's RR

d) Fever can increase a client's RR

A nurse is discussing the use of a client's thigh for BP measurements with an AP. Which of the following information should the nurse include? a) select a blood pressure cuff width that is 25% of the circumference of the client's thigh b) palpate the femoral pulse when obtaining BP in the thigh c) expect BP in the thigh to be 10 to 15 mm Hg less than in the arm d) Use the thigh to obtain blood pressure when a client has severe edema in their arms

d) Use the thigh to obtain blood pressure when a client has severe edema in their arms

A nurse is teaching a group of AP about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? a) a client who has a BP lower than the expected reference range b) a school-age client c) a client recovering from extensive abdominal surgery d) a client who has stabilized BP measurements

d) a client who has stabilized BP measurements

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an AP to obtain a rectal temperature? a) a toddler who has diarrhea b) a client who is 1 day post op from hemorrhoid surgery c) an infant who is receiving IV fluids d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth

d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention? a) an adolescent who has a RR of 20/min b) an older adult with RR of 16/min c) an infant with RR of 52/min d) a school-age child who has a RR of 14/min

d) a school-age child who has a RR of 14/min

A nurse is preparing an in-service for a group of newly hired APs about body temperature. Which of the following information should the nurse include? a) wait 5 min after a client has consumed a hot drink to obtain an oral temperature b) place a tape of patch thermometer over a client's scapula c) a tympanic thermometer reflects a client's body surface temperature d) a temporal probe thermometer uses infrared scanning to determine a client's temperature

d) a temporal probe thermometer uses infrared scanning to determine a client's temperature

A nurse obtains a client's electronic BP reading of 188/96 mm Hg. Which of the following actions should the nurse take next? a) provide client teaching regarding medications to control BP b) notify the provider of the clients BP reading c) provide the client education on measurements to decrease BP d) obtain a manual BP reading from the client

d) obtain a manual BP reading from the client

A nurse is preparing an in-service about vital signs for a group of newly hired APs. Which of the following information should the nurse include about measuring body temperature? a) tympanic temperature can be affected by environmental temperature b) temporal temperature is inaccurate in children under 3 years old c) axillary temperature reflects rapid changes in a client's core body temperature d) oral temperature is easily accessible despite a client's position

d) oral temperature is easily accessible despite a client's position

The nurse should encourage post op hysterectomy client to cough and deep breath to

remove secretions from the client's airway and to prevent atelectasis