Exam #2 – Foundations - Chapters 12, 13, 8 and 9 (Vital Signs, Physical Assessment, Mobility and Safety)

What are the respiration ranges?

12/20

What are the pulse rate ranges?

60-100

What are the temperature ranges?

96.8-100.4

What is extension?

A movement that *increases* the angle

What is tachypnea?

A rate faster than 20/min

What is bradypnea?

A rate slower than 20/min

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B. A client who has emphysema and is receiving humidified oxygen at 3 L/min via a transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula

A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Incourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

A. Encourage the client to listen to soft music

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Ask the client if he is experiencing any pain in the leg

A. Evaluate pedal pulses

A nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

A. Romberg

A nurse is collecting data about a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary source data B. Experiential data C. Primary source data D. Quantitative data

A. Secondary source data

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

A. Speech-language pathologist

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies

A. Use the pain scale to determine the client's pain level

What is hypertension?

Abnormal extension beyond normal join ability

A nurse in a long-term care facility is attending to a group of clients. One of the clients is walking in the hallway, bumping into walls, and not responding to his name. Which of the following actions should the nurse perform first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication

B. Accompany the client back to his room

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? ( select all that apply) A. Instruct the client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein level D. Place pillows under the clients knees and lower extremities E. Assist the client to change positions often

B. Apply elastic stockings E. Assist the client to change positions often

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform first after the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every hour D. Provide ice chips per provider prescription

B. Check the client's vital signs

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

B. Evacuate the client from the room

A nurse is measuring a client's vital signs. The clients resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the radial pulse rate Check Answer Question Feedback Show Explanation

B. Measure the client's apical pulse rate

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse is collecting data from a client who is postoperative following knee surgery. The nurse observes a frayed electrical cord on the continuous passive motion (CPM) machine. Which of the following actions should the nurse take? A. Consult the surgeon about discontinuing the client's CPM therapy B. Unplug the CPM device and remove it from the client's room C. Wrap electrical tape around the frayed portion of the cord securely D. Perform passive range-of-motion

B. Unplug the CPM device and remove it from the client's room

What is dorsiflexion?

Backward bending of the hand or foot

What is hypertension?

Blood pressure that is above expected range

What is hypotension?

Blood pressure that is below/lower than expected range

What pulse rate is slower than 60/min?

Bradycardia

A nurse is preparing to collect data about the function of a client's trigeminal nerve or cranial nerve (CN) V. Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart

C. Cotton wisps

A nurse is measuring vital signs for a client and notices a pulse irregularity. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Data collection D. Implementation

C. Data collection

A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. Nutrition

A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Decal impaction

C. Pressure injury

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia

C. Tachycardia

A nurse is collecting data from a female client who reports abdominal pain. Further findings reveal a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105 B. Soft nontender abdomen C. Temperature D. Overdue menses

C. Temperature

A nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button so I don't get an overdose." B. "If I push the button and still have pain after 2 minutes, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my TENS unit even though I'm pushing the PCA button."

D. "I can still use my TENS unit even though I'm pushing the PCA button."

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed

D. Advise the client to perform range-of-motion exercises while in bed

A nurse is taking a client's vital signs. Which of the following findings is outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38°C (100.4°F) C. Pulse oximetry 95% D. BP 145/90 mmHg

D. BP 145/90 mmHg

A nurse finds a client sitting on the floor by the toilet in the bathroom adjacent to his room. He states that he is fine after slipping on the tile floor but is having difficulty getting up. Which of the following actions should the nurse take first? A. Remind the client to use the call light to summon help when he needs to use the bathroom B. Help the client to return to bed and rest C. Complete an incident report according to the facility's policy D. Collect data from the client about any health alterations before, during, or after the fall

D. Collect data from the client about any health alterations before, during, or after the fall

A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine. 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? A. Turn on the machine every 15 min to measure the client's blood pressure B. Record only blood pressure readings needed for the 15-min intervals C. Obtain manual and automatic readings and compare them D. Disconnect the machine and measure the blood pressure manually every 15 min

D. Disconnect the machine and measure the blood pressure manually every 15 min

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

D. Temporal

A nurse enters a client's room and notices smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke

D. Transport the client to an area away from the smoke

What is flexion?

Decreasing the angle of a joint

How do you obtain a pulse oximeters?

Device use to measure the oxygen saturation. The pulse oximeter is a noninvasive device: the probe is usually placed on the patients finger.

What is a low point referred as?

Diastolic

What does pulse pressure mean?

Difference between systolic and diastolic pressure (usually 30 to 40 mm Hg)

What is the use of proper body mechanisms?

Keeping your center of gravity over a wide base support (your feet) during strenuous activities

What is prone position?

Lying flat on the abdomen, often with the head turned to one side

What is supine position?

Lying on the back, face up?

How do you measure orthostatic blood pressure?

Measure blood pressure and heart rate with the patient supine; wait 3 minutes, then have the patient stand up; now repeat the measurements

What is abduction?

Movement away from the midline

What is adduction?

Movement toward the midline

What is circumduction?

Moving in a circle at a joint

What is oxygen saturation?

Percentage of hemoglobin that is saturated with oxygen

How do you do a capillary refill?

Press the nail beds distal to the injury until blanching occurs (pressure should be applied for 3-5s. Blood returns to usual color with 3 s and 5s for older patients

How do you take a tympanic reading?

Remove the tympanic thermometer from its holder and place a probe cover on the thermometer tip without touching the probe cover with your hands. Turn the device on. Ask the patient to keep their head still. For an adult or older child, gently pull the helix (outer ear) up and back to visualize the ear canal. For an infant or child under age 3, gently pull the helix down. Insert the probe just inside the ear canal but never force the thermometer into the ear. The device will beep within a few seconds after the temperature is measured. Read the results displayed, discard the probe cover in the garbage (without touching the cover), and then place the device back into the holder

What is pronation?

Rotating the forearm so the palm is facing downward

What is supination?

Rotating the forearm so the palm is facing up

What is the term of body mechanisms?

Safe use of the body to maintain balance, posture, and alignment during movement (bending, lifting, and walking)

What is a high point referred as?

Systolic

What pulse rate is faster than 100/min?

Tachycardia

What is pulse deficit?

The difference between apical and radial pulse rates

What are the complications of immobility?

muscle atrophy, contractures, pressure ulcer, constipation, osteroporosis, pneumonia

What are the blood pressure ranges?

normal 120/80 low 90/60