Chapter 21 Fundamentals

Which is the most appropriate way to measure temperature in a patient who presents with atrial flutter and has a history of seizures?

Axillary

The nurse is evaluating vital sign trends for a 73-year-old male patient to determine needs. Based on the documentation in the health record, which action would the nurse perform? Chart/Exhibit 1 Temperature 97.3 °F Apical pulse 83 beats/minute Radial pulse 82 beats/ minute Respirations 18 breaths/minute Lying blood pressure 134/72 mmHg Standing blood pressure 98/59 mmHg Oxygen saturation 95% room air

Changing positions slowly

Which action would the nurse perform next if obtaining a blood pressure on a patient of 160/100 mm Hg?

Checking the blood pressure again, ensuring proper technique

Which reading indicates hypertension? Select all that apply. One, some, or all responses may be correct.

145/100 mm Hg 160/99 mm Hg

Which intervention would the nurse perform when a patient who was recently prescribed an antihypertensive medication reports dizziness, blurred vision, and feeling faint shortly after taking the medication?

Checking the blood pressure while the patient is sitting and again when the patient is standing

Which respiratory pattern consists of respirations that are fast and deep, then slower, and then followed by a period of apnea for 21 seconds, with continuation of this cycle?

Cheyne-Stokes respirations

Arrange the steps to be taken in the correct order when cleaning a thermometer in the home care setting

1. Clean the thermometer with a tissue and wipe from tip to bulb. 2. Wash the thermometer with warm, soapy water. 3. Rinse the thermometer with cold water without soap. 4. Disinfect the thermometer in 70% isopropyl alcohol and water. 5. Rinse, dry, and store the thermometer in a dry container

Which respiratory rate finding would indicate tachypnea in an adult? Select all that apply. 12 to 20 breaths/min One, some, or all responses may be correct.

30 breaths/min 24 breaths/min

The nurse is recording vital signs in the health record for a patient. Based on the documentation in the health record, calculate the number the nurse would document as the patient's pulse pressure. Record answer as a whole number.

56 Rationale The pulse pressure would be calculated by subtracting the diastolic from the systolic blood pressure reading. Therefore the pulse pressure would be calculated as 128 - 72 = 56.

The nurse is preparing to obtain a temperature from several patients on the unit. Which patient would require the use of a tympanic thermometer?

6-month old patient with croup

What is the pulse deficit in a patient with an apical pulse rate of 90 beats per minute (bpm) and a radial pulse rate of 60 bpm? Record your answer using a whole number

90-60=30 Answer : 30

Which pattern of temperature change during the day would the nurse expect in a patient who has been diagnosed with remittent fever and has a temperature of 103°F in the morning?

Increases in the afternoon and reaches 104°F by evening

Which action would the nurse perform for a 2-year-old patient who turns the head away and moves during a tympanic temperature reading?

Advising the mother to hold the child's head against her body to help check the temperature

Which mechanism regulates body temperature?

Air movement causing heat to be transferred from the skin to the air molecules by convection

Which patient has an abnormal pulse rate?

An 80-year-old female patient with 110 bpm

Question 50 Which patient factor would warrant the use of a tympanic thermometer? Select all that apply. One, some, or all responses may be correct.

Infant Tachypnea

Which nursing action would be the priority if a patient with sepsis has shallow respirations and a period of apnea after three breaths?

Informing the primary health care provider

Which action would the nurse perform when finding that a patient's blood pressure has remained 170/90 mm Hg over the past 3 days?

Informing the primary health care provider immediately

Which conclusion would the nurse make about a patient's core temperature if the oral temperature at 9:00 a.m. was 100.4°F (38.0°C) and the rectal temperature for the same patient was 100.4°F (38.0°C) at 10:00 a.m.?

It has decreased.

Which organ can be permanently damaged by long-tern uncontrolled hypertension?

Kidney

Which patient position would be correct to obtain a rectal temperature? Select all that apply. One, some, or all responses may be correct.

Knees flexed slightly while turning Turned to the side away from the nurse

The nurse is reviewing the health record of a patient brought to the emergency department with a blood glucose level of 640 mg/dL. Which breathing pattern would the nurse expect to find during the assessment?

Kussmauke respirations

Which type of respirations would occur in a patient with diabetes mellitus who presents with panting and grunting respirations at 40 breaths per minute (breaths/min)?

Kussmaul

In which area would the nurse place a stethoscope to auscultate an apical pulse on a patient?

Left fifth intercostal space in the right midclavicular line

The nurse recognizes that which medication has a normal side effect of a blood pressure of 120/80 mm Hg in sitting position and 100/80 mm Hg in standing position?

Losartan

The nurse knows that which difference defines a pulse deficit?

Apical and radial pulse

Which vital sign is most important to measure in a patient who is prescribed a diuretic and presents with reports of dizziness and blurred vision while standing or walking?

Blood pressure

Which vital sign falls within the established normal limits for a healthy adult? Select all that apply. One, some, or all responses may be correct.

Blood pressure of 119/70 mm Hg Temperature of 99.3°F (37.4°C) Heart rate of 62 beats per minute (bpm) Respiratory rate of 13 breaths/min

Which artery is most commonly used to assess the blood pressure of an adult patient?

Brachial

Which assessment would be the priority when the nurse notes a respiratory rate of 26 breaths per minute (breaths/min)?

Breath sounds Peripheral oxygen saturation

Which technique would be correct to count the pulse of a patient with an irregular pulse? Select all that apply. One, some, or all responses may be correct.

Counting the pulse for a complete minute Counting the first beat as zero and the next beat as one

Which additional sign would the nurse expect to observe in a postsurgical patient related to restlessness, a blood oxygen saturation reading of 67%, and a respiratory rate of 6 breaths per minute (breaths/min)?

Cyanosis

Which additional finding would the nurse note in a patient who presents with a respiratory rate of 10 breaths per minute (breaths/min) and shallow breathing.? Select all that apply. One, some, or all responses may be correct.

Cyanosis Confusion Dizziness

Which finding would the nurse expect when assessing a patient's breathing who has sustained a head injury as a result of a motor vehicle accident?

Decreased respiratory rate and shallow breathing

Which measure would the nurse take to manage the temperature of a patient who presents with a reading of 104°F?

Decreasing the room temperature Removing items of clothing or bed covers Encouraging increased oral intake of fluids

Which reason is most likely for a normothermic and eupneic patient to present with syncope, fatigue, and blurred vision; blood pressure of 110/90 mm Hg when sitting and 90/80 mm Hg when standing; and a heart rate of 110 beats per minute (bpm)?

Dehydration

Which other finding would the nurse expect in a patient who is brought to the emergency department after having a temperature of 105.9°F for 2 days? Select all that apply. One, some, or all responses may be correct.

Delirium Dehydration Convulsions

Which symptom would the nurse recognize as being associated with a prolonged, high fever? Select all that apply. One, some, or all responses may be correct.

Delirium Dehydration Convulsions

_________is the lower pressure exerted on the artery when the heart is at rest between And ___________is the maximum pressure exerted on the artery during left contractions, and ventricular contraction.

Diastolic blood pressure, systolic blood pressure

Which pulse site would the nurse assess to determine circulation of blood to the foot?

Dorsalis pedis Posterior tibial

Which situation would cause the body temperature to increase above baseline? Select all that apply. One, some, or all responses may be correct.

During physical or emotional stress During the evening, maximum at 4:00 p.m After long distance of running

Which condition would concern the nurse when obtaining a temperature of 99.2°F, pulse of 80 beats per minute (bpm), blood pressure of 130/85 mm Hg, and respiratory rate of 16 breaths per minute (breaths/min) from an 85-year-old patient?

Fever

At which area would the nurse assess the apical pulse?

Fifth intercostal space on the left midclavicular line

The nurse is planning to obtain an oral temperature from a patient. Which action would the nurse perform to obtain a rapid accurate oral temperature?

Having the patient remove gum

Which change in vital signs occurs in the older adult?

Heart rhythm may be slightly irregular.

Which factor affects heart rate? Select all that apply. One, some, or all responses may be correct.

Hemorrhage Blood pressure Emotional status Body temperature

Which condition could be the cause of pallor, skin mottling, clamminess, confusion, and low blood pressure in a patient?

Hemorrhage Myocardial infarction

The nurse is preparing to obtain a blood pressure for a patient before giving medication. Based on the information in the health record, which action would the nurse perform? Chart/Exhibit 1 55-year-old female • Height: 5'6" • Weight: 150 lb • Hypertension • Tyle 1 diabetes mellitus •• Chronic kidney disease Arteriovenous fistula right arm • High cholesterol levels

Measuring the blood pressure on the left arm

Which action would the nurse perform next when obtaining a 103°F temperature using a thermometer with a low battery?

Measuring the temperature again when the battery is replaced

The nurse is preparing to obtain an apical heart rate of a patient before administering medication. Which action would the nurse include in the planning stage? Select all that apply. One, some, or all responses may be correct.

Muting the television

Which action would be the priority for a patient with septicemia whose blood pressure has decreased to 80/50 mm Hg, pulse rate is 105 beats per minute (bpm), and skin has become cold?

Notifying the primary health care provider immediately

Which action would the nurse perform when a patient's vital signs have significantly changed from the previous check after confirming that the measurements are correct

Notifying the primary healthcare provider

Which nursing action would be appropriate when measuring core body temperature on an unconscious patient?

Obtaining a temperature with a rectal thermometer

Which action would the nurse perform if a patient's blood pressure

Obtaining the blood pressure using a manual sphygmomanometer

Which statement accurately describes the oral temperature, axillary temperature, rectal temperature, and tympanic temperature of a patient?

Oral temperature is more reliable than axillary temperature.

Arrange the steps to be taken in the correct order when measuring the blood pressure of a patient

Palpate the brachial or radial pulse. Inflate the bloed pressure cuff. Deflate the blood pressure cuff. Listen for Korotkoff sounds

The nurse is taking a blood pressure from a patient and cannot hear the Korotkoff sounds. Which action would the nurse perform to obtain an accurate reading?

Palpating for a radial pulse while performing the procedure

The nurse is reviewing the health record of the following patients before obtaining vital signs. In which patient would the nurse refrain from obtaining an oral temperature with a glass thermometer? Select all that apply. One, some, or all responses may be correct. Chart/Exhibit 1 Patient A Patient B Patient C Patient D Patient E 35-year-old male • Seizure disorder • 45-year-old male • Asthma exacerbation • 55-year-old female • Colorectal surgery • 65-year-old male • Atrial fibrillation • 75-year-old female • Alzheimer's disease

Patient A 35-year-old male Seizure disorder

The nurse is examining the health records of several patients on the unit before obtaining Patient A • 55-year-old male • Hypertension Patient B • 60-year-old male • Pneumonia Patient C • 65-year-old female • Heart dysrhythmias Patient D • 70-year-old male • Influenza A

Patient C

Which method would the nurse use to assess the temperature of a patient who has a warm and swollen area over the right mandibular region?

Place the axillary thermometer in the center of the dry right axilla.

Which is the probable reason for high blood pressure in a patient who has a diagnosis of polycythemia and has been prescribed acetaminophen, losartan, and ampicillin as home medications?

Polycythemia

The nurse is observing the unlicensed assistive personnel (UAP) obtain a blood pressure from an older adult patient with a history of hypertension. Which action by the UAP would necessitate the nurse to intervene? Select all that apply. One, some, or all responses may be correct.

Positioning the cuff over the antecubital space Deflating the cuff at 10 mm Hg per second Placing the bell of the stethoscope firmly on the skin Listening for Korotkoff sounds over the gown Inflating the cuff before finding a brachial pulse

Which technique would the nurse use to measure a patient's blood pressure?

Positioning the patient in a chair with the brachial artery at the level of the right atrium

The nurse is counting respirations for a patient while taking vital signs. Which action would the nurse perform to obtain an accurate reading?

Pretending to take a pulse while counting

Which intervention would the nurse perform for a patient who presents with frostbite on the right toe?

Providing a warm blanket Adjusting the room temperature to 72°F (22.2°C) or higher Submerging the patient's right foot in 107°F (41.7°C) warm water . Encouraging the patient to contract and relax the muscles

Which datum would the nurse collect when measuring vital signs? Select all that apply. One, some, or all responses may be correct.

Pulse Temperature Blood pressure Respiration rate Oxygen saturation

The nurse obtained the vital signs of a patient admitted with pneumonia. Based on the documentation in the health record, which term would the nurse use when documenting the vital signs? Temperature 97.5 °F Apical heart rate 84 beats/minute Radial pulse 68 beats/minute Respirations 18 breaths/minute Blood pressure 132/75 mmHg Oxygen saturation 95% on oxygen

Pulse deficit

Which method is correct when measuring blood pressure using a manual sphygmomanometer?

Reinflating the cuff 30 mm Hg higher than the point where the pulse disappeared

Which action would be the nurse's priority when a patient arrives at the emergency department suffering from a serious gunshot wound with a blood pressure of 90/60 mm Hg, heart rate of 130 beats per minute (bpm), and cold and clammy skin?

Reporting the signs and symptoms to the charge nurse or primary health care provider

The nurse is planning care for a patient who is receiving opioid analgesics after undergoing a surgical procedure. Based on the documentation in the health record, which vital sign would require immediate intervention? Chart/Exhibit 1 Temperature 97.9 °F (36.6 °C) Radial pulse 82 beats/minute Respirations 18 breaths/minute Blood pressure 128/72 mmHg Oxygen saturation 97% room air Vital Signs 1200 Temperature 98.2 °F (36.7 °C) Radial pulse 69 beats/minute Respirations 9 breaths/minute • Blood pressure 117/68 mmHg Oxygen saturation 95% room air

Respirations

Which vital sign would the nurse evaluate before administering morphine to a patient with a history of hepatic carcinoma?

Respiratory rate

Which vital sign of a healthy 30-year-old patient would be most concerning to the nurse

Respiratory rate of 10 breaths per minute

The nurse enters a patient's room to obtain an oral temperature. After explaining the procedure to the patient, in which location would the nurse place the oral probe?

Side sublingual pocket

What does the Phase V Korotkoff sound resemble?

Silence

Which information would the nurse provide when a patient asks why her temperature reading is not a consistent number?

Some medications can change the body temperature. Emotions and hormones can affect the body temperature. Body temperature may increase in response to invasion by pathogens.

The nurse is auscultating lung sounds of a patient being treated for pneumonia caused by rib fractures from a fall. Which breath sound heard by the nurse would require immediate intervention?

Stridor

Which type of breath sound noted in a child with croup is audible as a loud crowing noise on inspiration?

Stridor

The nurse knows that which statement is correct regarding the organs of respiration?

Surfactant is necessary for alveoli to remain open

Which datum indicates pyrexia?

Temperature of 100.8°F (38.2° C)

Which statement regarding respiratory assessment is correct? Select all that apply. One, some, or all responses may be correct.

The normal respiratory rate for a healthy adult is 12 to 20 breaths per minute (breaths/min). Noting the depth, rate, and pattern is part of respiratory assessment.

Which information about temperature changes during ovulation would the nurse provide a patient who is trying to avoid pregnancy?

There is a slight decrease in temperature before ovulation and an increase of 1°F above normal during ovulation.

Which area would the nurse use while checking the blood pressure of a patient whose right elbow and left humerus are fractured?

Thigh

Which finger placement would the student nurse use to measure a patient's pulse rate?

Two or three fingers lightly over the radial artery

The nurse is observing the unlicensed assistive personnel (UAP) obtain an oral temperature from a patient. Which action would require the nurse to intervene?

Uses red-colored probe

Which action would the nurse perform when having difficulty obtaining the blood pressure reading of a patient using a sphygmomanometer? Select all that apply. One, some, or all responses may be correct.

Using a Doppler ultrasonic device Assessing for signs of reduced cardiac output Measuring the patient's pulse and respiratory rate

The nurse is reviewing the health record of a patient before obtaining the blood pressure. Based on the documentation in the health record, which action would the nurse perform? Chart/Exhibit 1 48-year-old male • Height: 5'10" • Weight: 280 l • Smokes 1 pack per day • Hypertension • High cholesterol levels

Using a large blood pressure cuff

Which action would the nurse perform to measure the blood pressure of a patient who is brought to the emergency department with dehydration; cold, clammy skin; and dizziness and whose blood pressure is difficult to hear?

Using the palpation method

The nurse is preparing to obtain a blood pressure from a patient with hypertension. Which action would the nurse perform to prevent an erroneous blood pressure reading?

Utilizing the correct size cuff

Which action would the nurse perform if on entering the room to measure temperature a patient is drinking coffee?

Waiting 15 to 30 minutes after the patient finishes the coffee to measure the temperature

Which nursing action would be appropriate when preparing to take a patient's temperature with a temporal thermometer and the nurse notes that the patient has been lying on one side with the forehead on the pillow?

Waiting for the skin to cool to room temperature and then checking the temperature

Which characteristic would the nurse expect when palpating the pulse of a patient who has been diagnosed with low stroke volume?

Weak pulse