Essentials to Nursing Exam- Nursing Skills Related to Vital Signs

The registered nurse is teaching a nursing student about teaching strategies for health promotion in patients. Which statement by the nursing student indicates a need for further learning?

"I should demonstrate assessment of carotid pulse to a young child."

Which site should the nurse assess to determine the status of circulation to the lower leg?

Popliteal

After measuring the temperature of the temporal artery, the nurse cleans the sensor with the alcohol swab. What is the rationale behind the nurse's action?

Preventing transmission of microorganisms

Which pulse is used by the nurse to teach athletes to monitor their heart rate?

Radial pulse

Which nursing interventions should be provided for patients with fever?

Reduce external covering Provide supplemental oxygen Identify febrile episode phases

Which priority nursing intervention should be implemented for a patient with hypothermia?

Removing the patient's wet clothes.

The registered nurse is delegating tasks to the nursing assistive personnel (NAP). Which tasks can be delegated to the NAP?

Reporting significant changes in the patient Considering factors related to the patient's history Obtaining pulse measurements at appropriate times

The registered nurse is teaching a nursing student about promoting health to manage body temperature. Which statement by the nursing student indicates a need for further teaching?

"Strenuous exercise in hot and humid weather is permitted."

For which patients should the nurse pull the ear pinna backward, up and out during temperature assessment at the tympanic membrane site?

Adults

The nurse is assessing the radial and apical pulse of a patient with an arrhythmia. Which anatomical landmark is located by the nurse in the given figure?

Angle of Louis

The nurse checks for the presence of earwax in a patient's ear canal before measuring tympanic membrane temperature with an electronic thermometer. What is the rationale behind this action?

Earwax blocks the clear optical pathway.

While assessing the body temperature of a patient after treatment, the nurse observes that the temperature has dropped 1 degree below the normal range. Which interventions should the nurse follow in this situation?

Eliminate drafts. Provide extra blankets. Monitor apical pulse rate.

The nurse is comparing the temperature reading with the patient's previous baseline temperature range. Which step of the nursing process is involved in this situation?

Evaluation

The registered nurse is teaching a nursing student about precautions to be followed while measuring blood pressure (BP). Which statements made by the nursing student indicate a need for further learning?

I should ask the patient to take deep breaths." "I should make the patient talk while taking readings." "I should apply the cuff to an extremity where intravenous fluids are infusing."

Which assessments should take place before measuring body temperature?

Identify the medications or treatments. Determine the pertinent laboratory values. Collect the previous baseline temperature.

While assessing the axillary temperature, the nurse raises the patient's arm away from the torso. What is the rationale behind this action?

Inspecting for the presence of lesions

The nurse is measuring the rectal temperature of an adult patient. The nurse gently inserts the thermometer probe into the anus of the patient up to 3 cm in the direction of the umbilicus. What is the rationale behind this nursing intervention?

It ensures exposure to blood vessels.

The nurse is caring for a patient with a temperature of 39.5° C (103.1° C). Which nursing interventions should be implemented to manage the patient's condition?

Keeping bed linens dry Providing measures to stimulate appetite Providing the patient with 8 to 10 glasses of fluids daily

The nurse is delegating a task of measuring a patient's oxygen saturation (SpO 2). Which instruction should be provided to the nursing assistive person (NAP)?

Select the appropriate sensor site.

The nurse is assessing the rectal temperature of a patient with an electronic thermometer. Which patient position would promote comfort?

Sims' position (with the upper leg flexed to promote comfort).

Which site should be used by the nurse to determine pulse in children?

Temporal

The nurse assesses the popliteal region to determine a patient's pulse. What would be the assessment criteria of this action?

To assess status of circulation to lower leg.

During the assessment of a patient's radial and apical pulses, the nurse also checks the most recent serum potassium result. What is the reason for this assessment by the nurse?

To determine the reason for increased pulse rate.

While assessing the apical pulse in a patient, the nurse places the diaphragm of the stethoscope in her palm for 10 seconds. What is the rationale for placing the stethoscope in the palm?

To ensure that the diaphragm is warm.

When assessing the patient's respiration, the nurse elevates the bed to 60 degrees in a sitting position. What is the rationale behind this intervention?

To promote ventilatory movement

Which site is preferred by the nurse to perform Allen's test?

Ulnar

Which sites should the nurse assess to determine the status of circulation to the hand?

Ulnar Radial

The registered nurse is teaching a nursing student about respiratory assessment. Which statement by the nursing student indicates the need for further learning?

"I should let the patient know that I am assessing respiration."

The registered nurse is teaching a student nurse about the interventions to be followed when the blood pressure is above the acceptable range. Which statement by the nursing student indicates effective learning?

"I should verify the correct size and placement of the cuff."

What would be the follow-up recommendation suggested by the primary health care provider to a patient with stage 1 hypertension?

1 month

For which patients does the nurse measure blood pressure (BP) by palpation?

Patient with severe blood loss Patient with decreased heart contractility

While assessing a patient, the nurse finds that the radial pulse is abnormal. Which pulse should the nurse assess next in this situation?

Apical

While assessing a patient with heart disease, the nurse observes that the radial pulse is 50 beats per minute. Which nursing interventions should the nurse perform immediately?

Assess both radial pulses. Measure apical pulse and radial pulse simultaneously. Perform complete assessment of all peripheral pulses.

The nurse is assessing the pulse of a patient after performing pulse oximetry. The pulse rate indicated on the oximeter is lower than the patient's apical pulse. Which immediate interventions should the nurse perform in this situation?

Assess for signs of altered cardiac output. Reposition sensor probe to an alternative site.

The nurse determines the appropriate site for measuring a patient's temperature. Which nursing process is involved in this step?

Assessment

When measuring the axillary temperature of a patient, how can the nurse ensure proper positioning of the probe against the blood vessels in the axilla?

By placing the probe into the center of the axilla By lowering the arm over the probe By placing the arm across the chest

Which action should the nurse avoid while assessing the blood pressure (BP) of a 10-month-old patient?

Choosing the cuff based on the name of the cuff.

The nurse is teaching a patient to monitor his/her heart rate. This action occurs during which step in the nursing process?

Implementation

Which intervention does the primary health care provider order the nurse to perform when blood pressure is insufficient for adequate perfusion and oxygenation of tissues?

Increase the rate of intravenous infusion.

While assessing the oral temperature of a patient using an electronic thermometer, the nurse asks the patient to close his or her lips. What is the rationale behind this instruction?

Maintains proper position of the probe.

How should the nurse determine the ventilatory rhythm in a patient?

Observing the chest or the abdomen.

Which drugs does the nurse expect to depress respiratory rate and depth?

Opioid analgesics Sedative hypnotics General anesthetics

The registered nurse delegates an nursing assistive person (NAP) to measure the temperature of an intubated patient. Which route selected by the NAP would be correct in this condition?

Oral route

Which requirement is necessary for measuring oxygen saturation in a patient with emphysema?

Oximeter

After assessing the blood pressure of four different patients, the primary health care provider recommends follow-up visits. For which patient would the primary health care provider recommend a recheck after 1 year?

Patient B Prehypertension

The nurse is providing care for four patients with different body temperatures. Which patient has hypothermia based on the intervention?

Patient B Monitors apical pulse rate and rhythm

For which patient would a follow-up visit within 1 week be recommended?

Patient with blood pressure (BP) 185/100 mm Hg

In which phase does the nurse observe blowing and whooshing sounds during blood pressure (BP) measurement?

Phase 2

The nurse is explaining the procedure of measuring oxygen saturation to a patient. This explanation occurs during which step in the nursing process?

Planning

While assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem until the cover locks in place. What is the reason behind this intervention?

Preventing transmission of microorganisms between patients.

The nurse is unable to obtain the blood pressure (BP) reading of a patient using a sphygmomanometer. The sphygmomanometer is working correctly. What should the nurse do next?

The nurse should use a Doppler ultrasonic device. The nurse should assess for signs of reduced cardiac output. The nurse should measure the patient's pulse and respiratory rate.