Chapter 29
The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Standard Text: Select all that apply. 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery.
Correct Answer: 2, 3 Rationale 1: The valve on the bulb needs to be closed to pump up the cuff. Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures. Rationale 3: The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level. Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements. Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery.
When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color
Correct Answer: 1 Rationale 1: Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading. Rationale 2: Environmental conditions do not affect an accurate oxygen saturation reading. Rationale 3: Nutrition does not affect an oxygen saturation reading. Rationale 4: Skin color does not affect an oxygen saturation reading.
The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking.
Correct Answer: 1 Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings. Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the clients skin must be dry for the thermometer to adhere to the skin. Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes.
The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound
Correct Answer: 1 Rationale 1: Phase 2 produces a muffled, whooshing, or swishing sound. Rationale 2: Phase 5, the final phase, is where the sound disappears. Rationale 3: Phase 1 of Korotkoffs sounds starts with a faint, clear tapping sound. Rationale 4: Phase 3 is marked by an increased intensity of sound.
The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar
Correct Answer: 1 Rationale 1: The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. Rationale 2: The femoral is not as accessible as the brachial. Rationale 3: The radial could be used but it is not as accurate as the brachial artery. Rationale 4: The ulnar could be used but it is not as accurate as the brachial artery.
The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery
Correct Answer: 1 Rationale 1: The cardiac catheterization client will need a thorough assessment because she is just returning to the nursing unit. Invasive procedures, such as a catheterization, will need to be closely assessed. More than likely a Doppler will be needed to ensure the pedal pulse is present and stable in the extremity used during the procedure. Unlicensed personnel are not usually delegated Doppler ultrasound device use. Rationale 2: The COPD client is a chronic condition client, and her vital signs would be considered routine. Rationale 3: The client with pneumonia nearing discharge would be considered medically stable. Therefore, assisting this client is within the UAPs capability. Rationale 4: The client who is 2 days post-op from gallbladder surgery would be considered medically stable. Therefore, assisting this client is within the UAPs capability.
The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136 72 4. 72 136
Correct Answer: 1 Rationale 1: The first tapping phase 1 Korotkoffs sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoffs sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72. Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure. Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign. Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use.
When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL
Correct Answer: 1 Rationale 1: When documenting the temperature in the client record, an axillary temperature should be recorded with an AX. Rationale 2: The letter O is not used when documenting a clients temperature. Rationale 3: The letter R would indicate a rectal temperature and not an axillary temperature. Rationale 4: The letters SL are not used when documenting a clients temperature.
When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Standard Text: Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level
Correct Answer: 1, 2, 3 Rationale 1: The respiratory centers and chemoreceptors respond to changes in the concentration of oxygen. Rationale 2: The respiratory centers and chemoreceptors respond to changes in the concentration of carbon dioxide. Rationale 3: The respiratory centers and chemoreceptors respond to changes in the concentration of hydrogen ions. Rationale 4: The respiratory centers and chemoreceptors do not respond to changes in the potassium level. Rationale 5: The respiratory centers and chemoreceptors do not respond to changes in the serum calcium level.
The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Standard Text: Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity
Correct Answer: 1, 2, 3 Rationale 1: When assessing the pulse, the nurse collects data about the rate. Rationale 2: When assessing the pulse, the nurse collects data about the rhythm. Rationale 3: When assessing the pulse, the nurse collects data about the volume. Rationale 4: Tone is not a characteristic of a pulse. Rationale 5: Viscosity is not a characteristic of a pulse.
Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Standard Text: Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment
Correct Answer: 1, 2, 3, 4 Rationale 1: Stimulation of the sympathetic nervous system increases cardiac output and vasoconstriction of the arterioles, increasing the blood pressure reading. Rationale 2: African Americans over 35 years of age tend to have higher blood pressures than do European Americans of the same age. Rationale 3: Both childhood and adult obesity predispose to hypertension. Rationale 4: Many medications, including caffeine, can increase or decrease the blood pressure. Rationale 5: Employment is not a factor that affects blood pressure.
Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Standard Text: Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area
Correct Answer: 1, 2, 3, 4 Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment. Rationale 2: When a client returns from surgery, the nurse should conduct the assessment. Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment. Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment. Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP.
A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Standard Text: Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun
Correct Answer: 1, 3, 4, 5 Rationale 1: Persons experiencing heat stroke may be delirious. Rationale 2: Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness. Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin. Rationale 4: Persons experiencing heat stroke often do not sweat. Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather.
When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress
Correct Answer: 2 Rationale 1: Depth is a term used when assessing edema. Rationale 2: When assessing peripheral pulses, one of the characteristics being assessed is rhythm, along with rate, volume, and equality. Rationale 3: Heart sounds are assessed with the apical pulse. Rationale 4: Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment.
A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress
Correct Answer: 2 Rationale 1: Exercise increases respiration rates. Rationale 2: Factors that decrease respirations include increased intracranial pressure. Rationale 3: Increased environmental temperatures increase respiration rates. Rationale 4: Stress increases respiration rates
The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal
Correct Answer: 2 Rationale 1: The axilla is the preferred site for newborns, not adults. Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart. Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.
The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine
Correct Answer: 2 Rationale 1: The prone position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations. Rationale 2: Persons in a semi-Fowlers position will better aid themselves and the nurse to assess their respiratory status. Rationale 3: The side-lying position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations. Rationale 4: The supine position increases the volume of blood inside the thoracic cavity and compresses the chest, compromising the clients respirations.
In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt
Correct Answer: 3 Rationale 1: Assessing the pulse before the cuff is inflated is not the pressure. Rationale 2: This is not the clients blood pressure if the cuff is just being deflated. Rationale 3: The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a clients blood pressure. Rationale 4: If the second pulsation is recorded, that would be an inaccurate reading.
While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature.
Correct Answer: 3 Rationale 1: Bathing the client in ice water would lower the clients temperature too fast, possibly causing hypothermia. Rationale 2: Giving a client an antipyretic requires a doctors order. Rationale 3: Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the clients tissues will allow the temperature to return to normal. Rationale 4: Dropping the temperature of the room would lower the clients temperature too fast, possibly causing hypothermia.
The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later.
Correct Answer: 3 Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice. Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading. Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment.
The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.
Correct Answer: 4 Rationale 1: A forceful radial pulse would be ideal for assessing a clients peripheral pulse. Rationale 2: Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation. Rationale 3: A bounding pulse is not easily obliterated. Rationale 4: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the clients pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites.
A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes
Correct Answer: 4 Rationale 1: A temperature reading of 98.6F is a normal finding and not an indication of heart failure. Rationale 2: A moderate amount of clear mucus is a normal finding and not an indication of heart failure. Rationale 3: A pulse oximetry reading of 96% is a normal finding and not an indication of heart failure. Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure
As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen.
Correct Answer: 4 Rationale 1: Allowing the client to take a few deep breaths will help but not quickly enough to compensate for the hypoxia experienced. Rationale 2: Continuing to suction continuously or intermittently will only decrease the saturation levels more. Rationale 3: Leaving the catheter in place obstructs air flow, thus compromising an already poor situation. Rationale 4: Not only does suctioning remove secretions, but it also removes the clients air. By stopping suctioning, the RN stops removing both. This allows the client to recoup from the procedure, and giving oxygen will also increase the saturation ability back to a normal range.
Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance
Correct Answer: 4 Rationale 1: Determinants of blood pressure such as blood viscosity mainly affect the systolic reading portion of the blood pressure. Rationale 2: Determinants of blood pressure such as blood volume mainly affect the systolic reading portion of the blood pressure. Rationale 3: Determinants of blood pressure such as pumping action of the heart mainly affect the systolic reading portion of the blood pressure. Rationale 4: Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance.
An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted.
Correct Answer: 4 Rationale 1: If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise. Rationale 2: Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Because this client is older, hormone fluctuations and ovulation will not impact the temperature. Rationale 3: Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased. Rationale 4: This client is older and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost.
While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site
Correct Answer: 4 Rationale 1: The information provided gives no indication that any health change has occurred. Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot. Rationale 3: There is no data given in regard to equipment malfunction, such as the nurses watch. Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse because assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot.
Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch
Correct Answer: 4 Rationale 1: To assess an altered level of consciousness, the nurse would most likely assess the clients apical pulse. Rationale 2: To assess for decreased urine output, the nurse would most likely assess the apical pulse. Rationale 3: For an irregular radial pulse, the nurse would most likely assess the apical pulse. Rationale 4: The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch.