Perfusion & Gas Exchange Questions from book
A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? a) Temporal artery b) Tympanic c) Chemical dot d) Rectal electronic
a) Temporal artery
A patient has an irregular, thready pulse. You decide to have a nursing assistant help you obtain the pulse deficit. You auscultate the apical pulse while the NAP measures the radial pulse simultaneously. The results are: apical pulse 88, radial pulse 74. The pulse deficit is _____________?
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The students locate the point of maximal impulse and reassess the patient's apical pulse before administering a cardiac medication. They agree the patient's pulse is irregular. How should the apical pulse be measured? a) Take the patient's apical pulse for 1 full minute. b) Take the patient's apical pulse for 30 seconds and multiply by 2. c) Take the patient's apical pulse for 15 seconds and multiply by 4. d) A Doppler should be used to obtain the apical pulse.
a) Take the patient's apical pulse for 1 full minute.
Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) a) A patient receiving a blood transfusion for chronic anemia. b) An elderly patient who needs assistance with feeding and dressing. c) An adult female in the recovery room following a hysterectomy. d) A child who is below the normal height and weight for his age. e) A young adult with a white blood count of 15,000/mm3.
a) A patient receiving a blood transfusion for chronic anemia. c) An adult female in the recovery room following a hysterectomy. e) A young adult with a white blood count of 15,000/mm3
Term Definition: a) Irregular rate and depth, characterized by alternating periods of apnea and hyperventilation. b) Rate is regular but greater than 20 breaths per minute. c) Rate is regular but less than 12 breaths per minute. d) Rapid, deep regular respiration, found in diabetic ketoacidosis.
___c__ bradypnea __a___Cheyne-Stokes ___d__Kussmaul ___b__tachypnea
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? a) "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature." b) "Since the soup was not hot, go ahead and take the patient's temperature." c) "Change to the red thermometer probe and take the patient's temperature rectally." d) "Take the patient's temperature using the axillary route and when you record the reading, add 1°F."
a) "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
How far should a rectal thermometer be inserted in an adult? a) 1.5 in (3.8 cm) b) 3.5 in (8.9 cm) c) 0.5 in (1.3 cm) d) 2 in (5 cm)
a) 1.5 in (3.8 cm)
Because the patient's BP reading was elevated, you want to have another nurse recheck the patient's BP reading. How long should you wait before taking the patient's BP reading again in the same arm? a) 2 minutes b) 5 minutes c) 2 months d) It is unnecessary to wait.
a) 2 minutes
The difference between systolic and diastolic pressure is called the blank________. a) Pulse pressure b) Pulse deficit
a) Pulse pressure
Which of the following patients may require more frequent temperature measurement and nursing assessment because they are at risk for an alteration in temperature? (Select all that apply.) a) A patient who is in the recovery room after having his gallbladder removed b) A patient with pneumonia c) A patient receiving a blood transfusion d) A patient who is receiving physical therapy e) A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
a) A patient who is in the recovery room after having his gallbladder removed b) A patient with pneumonia c) A patient receiving a blood transfusion e) A patient with cancer whose white blood cell (WBC) count is 2500 per mm³
Inspiration is a(n) ________ process. a) Active b) Passive
a) Active
Identify the patient(s) who are at higher risk for having an elevated BP reading. (Select all that apply.) a) An African-American b) A European-American c) A patient who just smoked a cigarette d) An obese patient e) An underweight patient f) A patient on diuretic therapy
a) An African-American c) A patient who just smoked a cigarette d) An obese patient
The nurse is ambulating the patient for the first time following the patient's lengthy time of being on bed rest. Which of the following would be an appropriate action by the nurse to determine the patient's activity tolerance? a) Assess vital signs before and after ambulating the patient. b) Assess vital signs before ambulating the patient to see if the patient is ready. c) Assess vital signs after ambulating the patient to see if they are out of normal range. d) Determine the patient tolerates activity if the patient does not fall.
a) Assess vital signs before and after ambulating the patient.
The skill of radial pulse measurement ________ be delegated to NAP. a) Can b) Cannot
a) Can
The NAP should be instructed to report any abnormalities that should be ________ by the nurse. a) Confirmed b) Denied
a) Confirmed
What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) a) Count the respiratory rate again for a full 60 seconds (1 minute). b) Tell the patient their breaths are being counted so the patient will breathe slower. c) Assess physiologic factors that may be causing the patient to breathe so fast. d) Administer a bronchodilator that will decrease the respiratory rate. e) Record this normal respiratory rate in the patient's medical record.
a) Count the respiratory rate again for a full 60 seconds (1 minute). c) Assess physiologic factors that may be causing the patient to breathe so fast.
________ pressure is the minimal pressure exerted against the arterial wall at all times. a) Diastolic b) Systolic
a) Diastolic
Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) a) Drinking a cold glass of water. b) Participation in physical therapy exercises. c) Infection. d) Room temperature. e) Patient's height.
a) Drinking a cold glass of water. b) Participation in physical therapy exercises. c) Infection. d) Room temperature.
You are assessing the patient for signs and symptoms of decreased cardiac output. Which of the following indicate abnormal cardiac function? (Select all that apply.) a) Dyspnea b) Chest pain c) Flat jugular veins d) Increased urine output e) Edema f) Cyanosis
a) Dyspnea b) Chest pain e) Edema f) Cyanosis
When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? (Select All That Apply) a) Have another nurse assess the patient's respiratory rate. b) Remove the patient's gown for better visualization of the patient's chest. c) Document the inability to visualize inspiration and expiration. d) Move the patient's arm over their chest and feel the rise and fall of the chest.
a) Have another nurse assess the patient's respiratory rate. b) Remove the patient's gown for better visualization of the patient's chest. c) Document the inability to visualize inspiration and expiration. d) Move the patient's arm over their chest and feel the rise and fall of the chest.
You are preparing to take a patient's temperature. Which of the following factors may affect the patient's oral temperature reading? (Select all that apply.) a) If the patient has recently smoked b) If the patient is to be discharged soon c) If the patient has recently consumed a hot or cold beverage d) If the patient has recently exercised e) Warmth of the room f) If the patient took an antihypertensive medication 30 minutes ago
a) If the patient has recently smoked c) If the patient has recently consumed a hot or cold beverage d) If the patient has recently exercised
When would you expect the patient's BP to be lowest? a) In the early morning b) Mid-day c) Early evening d) Midnight
a) In the early morning
The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? a) In the right arm b) In the left arm c) In the right leg d) In the left leg
a) In the right arm
Because older adults often maintain a ________ body temperature, a temperature within an acceptable range in an adult may reflect a fever in an older adult. a) Lower b) Higher
a) Lower
A temperature reading obtained at noon will likely be ________ the 6 PM reading. a) Lower than b) Higher than
a) Lower than
A young adult has come to the outpatient clinic with an injured right leg. You need to collect the patient's vital signs. You are to give the patient morphine to treat his pain. The drug book says to assess respirations before administration. Why is this necessary? a) Opioid analgesics in high doses may decrease the rate and depth of respirations. b) Acute pain may increase the rate and depth of respirations. c) It's necessary to make sure the patient is not allergic to morphine. d) The anxiety of receiving an injection will increase the patient's rate and depth of respiration.
a) Opioid analgesics in high doses may decrease the rate and depth of respirations.
Which of the following thermometers (and corresponding route) would be most accurate for monitoring rapid changes in core body temperature? a) Oral electronic thermometer b) Rectal electronic thermometer c) Tympanic thermometer d) Electronic thermometer used axillary e) Chemical thermometer (oral/skin) f) Temporal artery thermometer
a) Oral electronic thermometer f) Temporal artery thermometer
The nurse is observing the NAP take a patient's oral temperature. Which of the following actions, if performed by the NAP, requires corrective action? (Select all that apply.) a) The NAP attaches a red tip probe to the thermometer unit. b) Holding down the ejection button, the NAP slides a disposable plastic probe cover over probe stem. c) The NAP asks if the patient has consumed food or drink, chewed gum, or smoked in the last 30 minutes. d) The NAP places the thermometer probe under the front of the tongue. e) After obtaining the measurement, the NAP returns the thermometer to the charger.
a) The NAP attaches a red tip probe to the thermometer unit. b) Holding down the ejection button, the NAP slides a disposable plastic probe cover over probe stem. d) The NAP places the thermometer probe under the front of the tongue.
Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) a) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. b) The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. c) The NAP waits until a tone sounds to read the tympanic thermometer. d) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. e) The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.
a) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. b) The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use.
The new NAP is unable to palpate a patient's radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) a) The NAP is assessing for a pulse on the ulnar side of the wrist. b) The NAP is pressing down too hard on the patient's radial site. c) The NAP is assessing for a pulse on the thumb side of the wrist. d) The NAP failed to auscultate the patient's wrist with a stethoscope. e) The patient was previously reported to have a full, bounding pulse. f) The NAP assessed the patient's BP before taking the patient's pulse.
a) The NAP is assessing for a pulse on the ulnar side of the wrist. b) The NAP is pressing down too hard on the patient's radial site.
The nurse has delegated the task of temperature assessment to the NAP. Which information should be provided to the NAP? (Select all that apply. a) The patient's age. b) The type of temperature required. c) The patient's diagnosis. d) The frequency for taking or monitoring the temperature. e) What changes to report immediately to the nurse.
a) The type of temperature required. d) The frequency for taking or monitoring the temperature. e) What changes to report immediately to the nurse.
The student nurse caring for an elderly patient with heart failure determines the patient's pulse is irregular. The student asks a peer to help determine whether there is a pulse deficit. The student who took the apical pulse obtained a rate of 56 and irregular. The student who took the radial pulse obtained a rate of 72 and irregular. How could this best be explained? a) There was an error made in obtaining the pulse rates. b) The patient's pulse deficit is 16. c) The patient has ineffective cardiac contractions. d) The patient's dosage of cardiac medication needs adjustment.
a) There was an error made in obtaining the pulse rates.
Which of the following situations may affect a patient's vital signs? (Select all that apply.) a) Time of day. b) Occupation. c) Moving from lying to standing position. d) Pain rated as a 7 on 0-10 pain scale. e) Isolation precautions.
a) Time of day. c) Moving from lying to standing position. d) Pain rated as a 7 on 0-10 pain scale.
Respirations should be assessed at rest to allow for objective comparison of values. a) True b) False
a) True
The normal respiratory rate for an adult is 12 to 20 breaths per minute. a) True b) False
a) True
________ is the mechanical movement of gases into and out of the lungs. a) Ventilation b) Respiration
a) Ventilation
Which of the following may increase both rate and depth of respiration? (Select all that apply.) a) Walking 1 mile briskly. b) Having a pain level rating at 7 on a scale of 0-10. c) Feeling anxious when taking a test. d) Smoking a cigarette. e) Taking an opioid to relieve pain. f) Having an addiction problem with amphetamines/cocaine. g) Using a bronchodilator prior to exercise. h) Incurring a head injury from a motor vehicle accident.
a) Walking 1 mile briskly. c) Feeling anxious when taking a test. f) Having an addiction problem with amphetamines/cocaine
You just bought a new stethoscope. During practice in the skills lab, you try to auscultate your partner's apical pulse with the diaphragm of the stethoscope but are unable to hear any sound. What is the most logical reason for this? a) You need to turn the chest piece so sound may be heard from the diaphragm side. b) The earpieces are occluding your ear canals and you have the binaurals angled so the ear tips are pointing toward your face. c) You bought a stethoscope with tubing that is too long. d) You should be using the bell side to auscultate the apical pulse.
a) You need to turn the chest piece so sound may be heard from the diaphragm side.
If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? a) 37-39 °C (98.6-102.2 °F) b) 96.8-100.4 °F (36-38 °C) c) 35-36 °C (95-96.8 °F) d) 96.8-98.6 °F (36-37 °C)
b) 96.8-100.4 °F (36-38 °C)
You check the patient's baseline temperature reading and note that it was recorded as 98.6° F (37 °C). What would you expect the temperature reading to be if it was obtained using the rectal route? a) 98.6° F (37 °C) b) 99.5° F (37.5 °C) c) 97.7° F (36.5 °C) d) 99.1° F (37.3 °C)
b) 99.5° F (37.5 °C)
Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? a) An African-American patient with a systolic BP of 100. b) A football player with a diastolic BP of 94. c) An elderly patient with a systolic BP of 88. d) A pregnant woman with a diastolic BP of 67.
b) A football player with a diastolic BP of 94.
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) a) A newborn following a heelstick. b) A patient returning from the operating room. c) A patient who received morphine for pain. d) A student who is getting ready to take an exam. e) A patient who experienced a bleeding episode.
b) A patient returning from the operating room. c) A patient who received morphine for pain.
For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? a) A patient who is a double arm amputee following a motor vehicle accident. b) A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). c) A patient with a history of a right-sided cerebrovascular accident (stroke). d) A patient with an arteriovenous shunt located in the forearm for hemodialysis.
b) A patient with a deep vein thrombosis (blood clot, usually in the lower extremities).
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) a) An apical pulse of a patient who is to receive a cardiac drug. b) A radial pulse on a patient with a 1200 mL fluid restriction. c) A radial pulse of a patient in the emergency room with chest pain. d) A femoral pulse following a lower leg amputation. e) The temporal pulse of a child.
b) A radial pulse on a patient with a 1200 mL fluid restriction. e) The temporal pulse of a child.
Which of the following is likely to result in a higher temperature reading? (Select all that apply.) a) A temperature taken in the morning b) A temperature taken in the evening c) The temperature of a healthy elderly adult d) The temperature of a teenager who just ran a mile e) The temperature of a college student taking an exam
b) A temperature taken in the evening d) The temperature of a teenager who just ran a mile e) The temperature of a college student taking an exam
A 62-year-old man is admitted to the hospital with prostate cancer. He is to have his vital signs taken before going to surgery. Which of the following, if present, may increase the patient's pulse rate? (Select all that apply.) a) Elevated BP b) Acute pain c) Anxiety d) Fever e) A large dose of an opioid analgesic f) The patient's age
b) Acute pain c) Anxiety d) Fever
Which person would be expected to have the lowest body temperature? a) A 16-year-old who ran 1 mile. b) An 80-year-old who walked half a mile. c) A toddler who is febrile. d) A child playing softball.
b) An 80-year-old who walked half a mile.
A young adult has been admitted to the hospital with a fever of unknown origin. Intravenous (IV) fluids have been started, and the patient is feeling much better. You are going to take the patient's temperature. Which of the following would be the best thermometer selection? a) An electronic thermometer with a red probe end b) An electronic thermometer with a blue probe end c) A chemical thermometer (skin sensor)
b) An electronic thermometer with a blue probe end
The student nurse is unsure of the BP measurement. What should the student nurse do first? a) Wait 30 seconds and repeat the measurement on the same arm. b) Assess the BP in the other arm. c) Get the nurse to assess the BP. d) Determine if the patient received an antihypertensive medication.
b) Assess the BP in the other arm.
The NAP reports to the nurse a 65-year-old patient's blood pressure is 160/98. What is the appropriate initial response of the nurse? a) Ask the NAP if the patient is nauseous. b) Assess the patient's blood pressure. c) Instruct the NAP to obtain a full set of vital signs. d) Document this as a normal finding in an elderly adult.
b) Assess the patient's blood pressure.
1. Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? a) Check the carotid pulses one side at a time. b) Auscultate the apical pulse for quality and rate. c) Reassess the radial pulse for 30 seconds. d) Check the radial pulse on the opposite side.
b) Auscultate the apical pulse for quality and rate.
In what direction should the nurse pull the pinna of the adult when taking a tympanic temperature? a) Backward, down and out b) Backward, up, and out
b) Backward, up, and out
The skill of respiration measurement with a stable patient blank________ be delegated to NAP. a) Cannot b) Can
b) Can
A young adult has come to the outpatient clinic with an injured right leg. You need to collect the patient's vital signs. The best way to count a respiratory rate is: a) Count from the end of expiration through the beginning of inspiration. b) Count from the beginning of inspiration to the end of expiration. c) Count from the beginning of inspiration to the end of inspiration. d) Count from the beginning of expiration to the end of expiration.
b) Count from the beginning of inspiration to the end of expiration.
Orthostatic changes in vital signs are good indicators of blood volume __________. a) Expansion b) Depletion
b) Depletion
The patient's BP is 146/92. This is an average BP reading for a 70-year-old woman. a) True b) False
b) False
The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. a) True. b) False.
b) False.
The UAP (unlicensed personnel) reports to the nurse that the patient complains of "feeling funny." Which of the following would be an appropriate initial action made by the nurse? a) Notify the health care provider. b) Obtain a complete set of vital signs. c) Document the patient's complaint. d) Review the patient's medications.
b) Obtain a complete set of vital signs.
________ is the distribution of red blood cells to and from the pulmonary capillaries. a) Diffusion b) Perfusion
b) Perfusion
Which of the following actions could lead to an inaccurate temperature reading when using a temporal artery thermometer? a) Wiping the forehead with a towel before assessing the temperature. b) Releasing the scan button before putting the sensor behind the patient's ear. c) Keeping the probe flush on patient's skin while sliding the probe across forehead. d) Pressing the scan button with your thumb.
b) Releasing the scan button before putting the sensor behind the patient's ear.
If the patient is to receive a medication that requires an apical pulse before administration, it ________ be delegated to NAP. a) Should b) Should not
b) Should not
________ pressure is the peak pressure that occurs during contraction of the heart's ventricles. a) Diastolic b) Systolic
b) Systolic
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? a) Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. b) Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. c) Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. d) Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
b) Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%.
Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) a) An elderly patient with Type 1 diabetes who is otherwise healthy. b) The patient who was just informed of a diagnosis of cancer. c) A patient with peripheral vascular disease. d) A patient who is receiving bolus IV fluids. e) A patient with Alzheimer's disease.
b) The patient who was just informed of a diagnosis of cancer. c) A patient with peripheral vascular disease. d) A patient who is receiving bolus IV fluids.
The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? a) To practice the technique of blood pressure measurement. b) To determine if there is a difference in the readings between the two arms. c) To verify the BP reading is 10 mm Hg higher in the dominant arm. d) To assess for a pulse deficit and record this as a baseline measurement.
b) To determine if there is a difference in the readings between the two arms.
You take a patient's vital signs on admission to the hospital. Why is it important to take vital signs at this time? a) To complete the routine paperwork of the admission process b) To obtain a baseline measurement for comparison with subsequent vital sign measurements c) To determine how the experience of being hospitalized is affecting the patient d) To provide accuracy in measurement before the task is delegated to NAP for future assessment
b) To obtain a baseline measurement for comparison with subsequent vital sign measurements
The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) a) To determine whether the patient is "feeling funny" or different". b) To provide a set of vital signs to use for comparison during and after surgery. c) To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. d) To provide the patient with reassurance that he or she is being cared for by a competent staff. e) To ensure the equipment is appropriately calibrated and functional.
b) To provide a set of vital signs to use for comparison during and after surgery. c) To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention.
What is the normal pulse range for an adult? a) 120 to 160 beats per minute. b) 90 to 140 beats per minute. c) 60 to 100 beats per minute. d) 50 to 80 beats per minute.
c) 60 to 100 beats per minute.
The patient's temperature is 102.2 ºF (39 ºC). What action should you take? a) None, because this is an acceptable temperature for a young adult. b) None, because the patient's temperature is too low to institute measures to lower body temperature. c) Administer an antipyretic as ordered. d) Apply a hyperthermia blanket as ordered.
c) Administer an antipyretic as ordered.
Which of the following patients is exhibiting abnormal vital sign values for their age? a) Newborn: Temperature 98.6º F, pulse 130, respiration 35, mean BP 65/41, pulse oximetry 99% b) Adolescent: Temperature 37º C, pulse 84, respiration 16, BP 110/65, pulse oximetry 100% c) Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84% d) Older adult: Temperature 96.8º F, pulse 98, respiration 12, BP 116/76, pulse oximetry 95%
c) Adult: Temperature 96.7º F, pulse 55, respiration 24, BP 160/90, pulse oximetry 84%
Which of the following patients would require follow-up? a) A child with a respiratory rate of 20 breaths per minute. b) An adolescent with a respiratory rate of 16 breaths per minute. c) An adult with a respiratory rate of 10 breaths per minute. d) A newborn with a respiratory rate of 40 breaths per minute.
c) An adult with a respiratory rate of 10 breaths per minute.
When measuring an irregular radial pulse, you must: (Select all that apply.) a) Count the rate over 30 seconds and multiply the value by 2. b) Use a Doppler, as irregular pulses are difficult to palpate. c) Consider reassessing the patient using the apical site. d) Document that the patient has bradycardia. e) Count the rate over 60 seconds/1 full minute.
c) Consider reassessing the patient using the apical site. e) Count the rate over 60 seconds/1 full minute.
Which patient would it be appropriate for the nurse to delegate vital signs? a) New admission to the hospital. b) Patient transferred from ICU. c) Elderly nursing home resident. d) Patient with recent complaint of headache.
c) Elderly nursing home resident.
The cuff keeps popping off your patient's arm when you inflate it. To maintain accuracy of measurement, the best action you should take is: a) Hold the cuff while you inflate it so it won't pop off. b) Have someone help you by holding the cuff on the patient's arm so it won't pop off. c) Get a larger size cuff to take the patient's BP. d) Put the cuff around the patient's forearm and palpate the patient's BP. e) Take the patient's BP in the opposite arm.
c) Get a larger size cuff to take the patient's BP.
1. At the end of the clinical day, the nursing instructor notices that a student nurse has documented a resident having a temperature of 99.8° F (37.7° C) and that the student administered a flu shot. What should the student nurse have done? a) Notified the doctor of this change in patient condition. b) Administered an antipyretic along with the flu vaccine. c) Held the flu vaccine; notify supervisor or instructor of increase in temperature. d) Administered the flu vaccine and increased the resident's fluid intake.
c) Held the flu vaccine; notify supervisor or instructor of increase in temperature.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) a) Place the patient's feet in a tub of cool water with ice. b) Apply a hyperthermia blanket as ordered. c) Remove the patient's blankets. d) Limit the patient's fluid intake. e) Administer an antipyretic to the patient as ordered.
c) Remove the patient's blankets. e) Administer an antipyretic to the patient as ordered.
Which of the following charting entries depicts the most complete assessment of the vital sign respiration? a) The respiratory rate is 16 with a regular rhythm. b) Deep respirations are noted at a rate of 12 per minute. c) Respirations are nonlabored and regular at a rate of 20 per minute with normal depth. d) Respirations are shallow at a rate of 25 per minute. The patient complains of pain in the left lower leg, rated at a "7" on the pain scale.
c) Respirations are nonlabored and regular at a rate of 20 per minute with normal depth.
It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? a) The patient has a temperature of 99.0°F when assessed rectally. b) The patient has been NPO since midnight before the surgery. c) The patient complains of pain at a 9 on a 0-10 pain scale. d) The body is compensating for the cool environment of the surgical suite.
c) The patient complains of pain at a 9 on a 0-10 pain scale.
The student nurse has been given a list of patient names with instructions to obtain vital signs on each. The student nurse gathers the appropriate equipment and begins the task. The student nurse comes to the first patient and finds a small, frail, elderly woman. The electronic BP cuff wraps around the patient's arm several times. The BP machine obtains a reading of 84/52. The student nurse reassesses the measurement, using the same cuff. The reading now is 86/64. What is the best explanation for this change in BP reading? a) The patient is becoming anxious. b) The student nurse should have used a lower extremity to reassess the BP. c) The student nurse should have waited longer before repeating the assessment on the same extremity. d) The electronic BP machine probably needs recharging or to be plugged in.
c) The student nurse should have waited longer before repeating the assessment on the same extremity.
You check the patient's temperature using the axillary route, and the thermometer reads 97.9° F (36.6 °C). Which of the following would be the most accurate documentation of the reading? a) 97.9° F (36.6 °C) b) 98.8° F (37.1 °C) c) 97.0° F (36.1 °C) Ax. d) 97.9° F (36.6 °C) Ax.
d) 97.9° F (36.6 °C) Ax.
For which patient would a tympanic thermometer be the preferred thermometer to use? a) A marathon runner who developed weakness during the race. b) A newborn that requires continuous temperature monitoring. c) A pediatric patient who had tubes surgically placed in the ears. d) A tachypneic patient who is receiving oxygen by nasal cannula.
d) A tachypneic patient who is receiving oxygen by nasal cannula.
The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? a) When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. b) When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. c) When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. d) After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.
d) After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.
The nursing student administered morphine 5 mg IV at 1330 for pain to a postoperative knee replacement patient. The nursing student returned to the patient's room in 30 minutes to determine whether the medication was effective. The nursing student noticed that the patient's respirations were regular at 8 per minute. What would this breathing pattern be called? a) Tachypnea b) Cheyne-Stokes respiration c) Biot's respiration d) Bradypnea
d) Bradypnea
How can the nurse best obtain an accurate measurement of a patient's respiratory rate? a) Inform the patient when monitoring his or her respirations. b) Assess the respirations while the patient is talking. c) Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. d) Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
d) Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
The NAP reports to you that a patient is "feeling different" and appears less alert. Your first action should be to: a) Notify the health care provider. b) Inform the NAP of the patient's normal values for vital signs. c) Instruct the NAP to retake the vital signs and report back. d) Obtain the vital signs yourself. e) Instruct the NAP to continue to assess and monitor the patient closely.
d) Obtain the vital signs yourself.
Before taking the patient's temperature, the patient tells you they just drank some ice water. What is your best action? a) Praise the patient for increasing fluid intake because this will help lower body temperature. b) Take the patient's temperature orally and document that the patient reports having drank cold water before assessment. c) Take the patient's temperature by another route. d) Request that the patient refrain from eating or drinking until you return in 20 minutes to assess their oral temperature
d) Request that the patient refrain from eating or drinking until you return in 20 minutes to assess their oral temperature
The nurse is unable to obtain a BP reading using an electronic BP machine on a post-operative patient. The machine reads "Error." What priority action should the nurse take? a) Reattempt using a different electronic BP machine. b) Notify the health care provider of this change in patient condition. c) Increase the patient's rate of intravenous (IV) fluids. d) Take the patient's BP manually using a sphygmomanometer.
d) Take the patient's BP manually using a sphygmomanometer.
Where will you best be able to auscultate the patient's apical pulse? a) The right 2nd ICS b) The left 2nd ICS c) Erb's point d) The 5th ICS/left MCL
d) The 5th ICS/left MCL
The students are administering flu shots to the residents in a nursing home. Before administering the flu vaccine, the students have been instructed to obtain the vital signs, auscultate lung sounds, and document their findings in the residents' medical record. They should hold the flu vaccine if a resident's temperature is elevated. Why do you think the students have been asked to do this? a) To get more practice assessing vital signs and lung sounds. b) To prevent the resident from having an allergic reaction. c) To get to know the residents better before an invasive procedure. d) To verify the resident does not have a fever and can receive a flu shot.
d) To verify the resident does not have a fever and can receive a flu shot.
You enter the patient's room to take routine vital signs. You see that the patient has just finished exercising with physical therapy. What is your best action? a) Skip this routine vital sign assessment. b) Wait 30 minutes to 1 hour before assessing the pulse. c) Take the patient's radial pulse. d) Wait 5 to 10 minutes before assessing the pulse.
d) Wait 5 to 10 minutes before assessing the pulse.
