Fundamentals of Nursing: Module 3 Exam
The nurse was assigned to care for five patients. Which of the following vital signs measurements would be cause for concern?
-75 year old with pulse oximetry of 88% on room air. -65 year old with blood pressure of 140/90
The nurse decides to collect the patients temperature orally using an electric thermometer. Choose the equipment to be used.
-Blue probe electronic thermometer. -Thermometer cover. -Patient data recording sheet and a pen.
The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase ability rot auscultate the reading?
-Reduce environmental noise by turning off the TV or closing the door. -Ensure the stethoscope does not touch the patient's clothing or BP cuff. -Keep the stethoscope tubing still to avoid extraneous sound. -Ensure chest piece is rotated to the diaphragm side. -Ensure bladder of the cuff is centered 1 in above the brachial artery.
The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action should the nurse take?
-Verify the reading by taking the patient's pulse oximetry. -Assist the patient to a high-Fowlers position. -Be prepared to administer oxygen. -Perform a cardiopulmonary assessment. -Notify the health care provider.
The patient's BP reading is 150/80 mmHg. For the patient, 80 is representative of:
-diastolic pressure -the ventricles during relaxation
A 15-year old male patient is hypothermic. Which temperature reflects hypothermia?
95 F 35C
The patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be?
97.8F (36.5C), 110, 24, 80/40
Who would the nurse expect to have the highest body temperature reading?
An adult female who is walking.
Which of the following should the nurse report to the health care provider?
An adult patient with a heart rate of 55.
A nursing student is assigned to take the vital signs on the patient and finds the radial pulse to be irregular. What action should the nursing student take?
Auscultate the patient's apical pulse.
The nurse reads the following nurse's note in the patient's health record. What is the priority nursing intervention based on this information?
Obtain a complete set of vital signs and gather further assessment data.
A patient has been given an opioid analgesic for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose?
Opioid analgesic may depress rate and depth of respiration.
You are taking a patient's BP by using one-step method. Which of the following is an incorrect step in the sequence for performing this procedure?
Pump the cuff to 20mmHg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mmHg.
Which of the following vitals signs are expected for the adult patient who has problems in oxygenation?
Temp 98.6 F (37C), P-102, R-28, BP 98/50, O2 sat- 85%
A healthy 30-year old male arrives at the clinic for a physical. The nurse is responsible for collecting his vital signs. Which of the following can be delegated to a NAP?
Temperature -pulse -respirations -BP -pulse oximetry
Identify why a child's respirations might be shallow
The child is in acute pain
A teen has come to the health care provider's office because he does not feel well after football practice. His temperature is 102F. The nurse may conclude which of the following regarding temperature reading?
This is a high temperature for a person his age.
