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Adult Health 324 Study Guide Exam Best Exam Predictor
Typology: Exams
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The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition “An infectious disease like pneumonia may not pose a risk to others.” The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease “When camping, I will wear insect repellent.” The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers Wash their hands between each interaction with children. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient’s susceptibility to this infectious process “Do you have a chronic disease” The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse’s assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient’s temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first Utilize SBAR to notify the primary health care provider. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information
is most important for the nurse to include in the educational session Smoking affects the cilia lining the upper airways in the lungs. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority “What medications are you currently taking” The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response Edema, redness, tenderness, and loss of function Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response Rest, ice, and elevation The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection A patient who is recovering from a right total hip surgery The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure Maintain surgical aseptic technique. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse’s actions related to the teaching Stress for long periods of time can lead to exhaustion and decreased resistance to infection. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection Teaching the patient to select nutritious foods
A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection Don gloves and other appropriate personal protective equipment. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient Observe the patient for decreased activity tolerance. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care–associated infection Use a chlorhexidine wash. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI Allowing the drainage bag port to touch the graduated receptacle. Which nursing action will most likely increase a patient’s risk for developing a health care–associated infection Uses a clean technique for inserting a urinary catheter The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient’s cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is most appropriate for the nurse to take Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique Touching clean protective eyewear
The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene Removing gloves to transfer the endoscope The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions Wears eyewear when emptying the urinary drainage bag The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use Standard The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP The nurse is responsible for providing a safe environment for the patient. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next Wash hands with an antimicrobial soap and water. The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next Repeat handwashing using antiseptic soap.
The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure Sending to central sterile for cleaning and sterilization The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings The family member places the used dressings in a plastic bag. The nurse is caring for a group of patients. Which patient will the nurse see first A patient with Clostridium difficile in droplet precautions The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after Performing treatments The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next Apply a new mask. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next Instruct assistive personnel to use soap and water rather than sanitizer. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk Hepatitis B
The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next Immediately wash the site with soap and running water, and seek guidance from the manager. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area Testing the patient and offering treatment to the nurse The nurse is caring for a patient in protective environment. Which actions will the nurse take (Select all that apply.) Maintain airflow rate greater than 12 air exchanges/hr. Open drapes during the daytime. Listen to the patient’s interests. The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection (Select all that apply.) “Can you explain the risk for infection in your home” “Have you traveled outside of the United States” “Will you demonstrate how to wash your hands” “What are the signs and symptoms of infection” The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct (Select all that apply.) Touches only the inside of gown Slips arms into arm holes simultaneously Extended fingers fully into both of the gloves Uses hands covered by sleeves to open gloves The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take (Select all that apply.) With gloved dominant hand, slip fingers underneath second glove cuff. Lay glove package on clean flat surface above waistline. Glove the dominant hand of the nurse first.
After second glove is on, interlock hands.
The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient (Select all that apply.) Private room Negative-pressure airflow in room N95 respirator, gown, gloves, eyewear Communication signs for airborne precautions The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session (Select all that apply.) Dispose of supplies to prevent the spread of microorganisms. Wash hands before entering and leaving both of the patients’ rooms. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. Have patients in airborne precautions wear a mask during transportation to other departments.
A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up “When it is cold outside in the winter, I will use a nonvented furnace.” The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs The electricity was turned off 3 days ago. The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat 65° to 75° F
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately Temperature A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens Wash hands The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event A surgical sponge is left in the patient’s incision. The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next Notify the health care provider. When making rounds the nurse observes a purple wristband on a patient’s wrist. How will the nurse interpret this finding The patient has do not resuscitate preferences. A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls Orthostatic hypotension The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing Toddler A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session Proper fit of a bicycle helmet The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session
Increased aggressiveness and blood spots on clothing may indicate substance abuse. The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic “Smoking even at parties is not good for my body.” The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group “Are you able to hear the tornado sirens in your area” The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint The patient continues to remove the nasogastric tube. The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working The patient folds three washcloths over and over. The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take Assess the patient. The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly Which activity will cause the nurse to monitor for equipment-related accidents Uses a patient-controlled analgesic pump A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take Keep the patient on fall risk until discharge.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident Surgical asepsis A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals Uses medication bar coding when administering medications During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls The patient takes a hypnotic. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel Applying the restraint A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next Remove the restraint. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority Manage all patients using standard precautions. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan Risk for injury A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient Risk for injury: Check on patient every 15 minutes. The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient’s plan of care
Deficient knowledge The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene “If my grandchild eats a plant, I should provide syrup of ipecac.” A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up Plastic grocery bags are neatly stored under the counter. Which patient will the nurse see first A 56-year-old patient with oxygen using an electric razor for grooming A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session Disconnect items before cleaning. The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action The patient wears the red nonslip footwear. An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient Backs wheelchair into elevator, leading with large rear wheels first A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene (Select all that apply.) Smoking in bed helps me relax and fall asleep. We use the same space heater my grandparents used. We use the RACE method when using the fire extinguisher. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session (Select all that apply.)
Walk to the mailbox in the summer. Encourage yearly eye examinations. Keep pathways clutter free. A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care (Select all that apply.) Health care provider writes the type and location of the restraint. Health care provider performs a face-to-face assessment prior to the order. Health care provider specifies the duration and circumstances under which the restraint will be used. The nurse is performing the “Timed Get Up and Go (TUG)” assessment. Which actions will the nurse take (Select all that apply.) Instructs the patient to walk 10 feet as quickly and safely as possible Observes for unsteadiness in patient’s gait Allows the patient a practice trial The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family (Select all that apply.) Discuss with the family steps to take if the seizure does not discontinue. Instruct the family to reorient and reassure the patient after consciousness is regained. The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient (Select all that apply.) Where did you fall What time did the fall occur What were you doing when you fell What types of injuries occurred after the fall The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take (Select all that apply.) Close all doors. Note evacuation routes. Note oxygen shut-offs. Move bedridden patients in their bed.
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient’s medical record to provide safe care (Select all that apply.) Patient is placed in bilateral wrist restraints at 0815. Bilateral radial pulses present, 2+, hands warm to touch Attempts to distract the patient with television are unsuccessful. Released from restraints, active range-of-motion exercises completed
A nurse is assessing body alignment. What is the nurse monitoring The relationship of one body part to another while in different positions A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take Moves patient’s arm until thumb is upward and lateral to head with elbow flexed A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement Each movement is moved just to the point of resistance by the nurse. A nurse is performing passive range of motion (ROM) and splinting on an at- risk patient. Which finding will indicate goal achievement for the nurse’s action Prevention of joint contractures A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel Changing the patient’s position
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition Blood pressure cuff The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first Dangle the patient at the bedside. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient Renal calculi A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient Altered nutrient metabolism A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider Loss of hope The nurse is preparing to lift a patient. Which action will the nurse take first Assess weight and determine assistance needs. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan Encourage the patient to perform as many self-care activities as possible. The nurse is observing the way a patient walks. Which aspect is the nurse assessing Gait A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal When observed laterally, the spinal curves align in a reversed “S” pattern.
The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding Both feet are supported on the floor with ankles flexed. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use Lateral position The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system Auscultate the entire lung region to assess lung sounds. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take Measure the calf circumference of both legs. A nurse is assessing the skin of an immobilized patient. What will the nurse do Use a standardized tool such as the Braden Scale. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings These are common manifestation with UTIs. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess Imbalance Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan A patient who is not completely immobile The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take Assist the patient with comfort measures. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take
Establish goals that are measurable and realistic. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility Consults physical therapy for strengthening exercises in the extremities The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning At the time of admission Which goal is most appropriate for a patient who has had a total hip replacement The patient will walk 100 feet using a walker by the time of discharge. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent Back A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do Monitor intake of vitamin D. A nurse is providing care to a group of patients. Which patient will the nurse see first A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient Low-molecular-weight heparin doses Flex knees and hips and on count of three shift weight from the front to back leg. 3, 4, 1, 5, 6, 2 The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take
Place pillow under the patient’s abdomen after turning. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation A trochanter roll The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe Use a friction-reducing device. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient’s toes. Which device will the nurse use A foot cradle A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome Patient is lying on side. A nurse is evaluating care of an immobilized patient. Which action will the nurse take Compare the patient’s actual outcomes with the outcomes in the care plan. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care A patient with neck surgery The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend High protein, high calorie The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy
As soon as the ability to move is lost The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for “ROM as needed.” What should the nurse do next Further assess the patient. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which areas will the nurse observe Ileum, clavicle, knees The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient Assist with ambulation and measure how far the patient walks. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling Use at least three people. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take (Select all that apply.) Consult a dietitian Increase frequency of turning. Place on pressure-relieving mattress. The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient (Select all that apply.) Footdrop Hypostatic pneumonia Impaired skin integrity
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely Temperature A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss Convection The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature Conduction A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take Place a cap on their heads. The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do Realize that this is a normal temperature variation. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take Wait 30 minutes and recheck the patient’s temperature. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition Thermometer The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient Hyperthermia occurs when the body cannot reduce heat production. The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take
Place the patient on oxygen. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN Assessing changes in body temperature The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature Tympanic The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading Tympanic The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse Brachial The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use Carotid The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist. The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate Obtain without the patient knowing. The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure 80 The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check
Hematocrit The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do Use oxygen cautiously in this patient. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up 50 mm Hg The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate The patient has calcium channel blockers or digitalis medication prescriptions. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation Place a nonadhesive sensor on the patient’s earlobe. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms Hemoglobin level of 8.0 g/100 mL A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension 120/80 in a middle-aged adult The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address African-Americans A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP) Smoking result in vasoconstriction, falsely elevating BP.
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding This is normal for an infant. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding The patient has a normal temperature. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action It has no risk of injury to patient or nurse. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP Brachial site The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn 30 to 60 The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take Determine whether the toddler has a latex allergy. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed Explain the procedure to the child. A nurse is caring for a group of patients. Which patient will the nurse see first A calm adolescent with P-95 and R-26 The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse
recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient You will need to recalibrate the machine. The nurse is caring for a patient who reports feeling light-headed and “woozy.” The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do Perform an apical/radial pulse assessment. A nurse is caring for a group of patients. Which patient will the nurse see first A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take Documents that the medication was not given because of low blood pressure After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action Temperatures vary depending on the route used. When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding 138/62 The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next Retake the blood pressure personally and assess the patient’s condition.
A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature (Select all that apply.) Tympanic Esophagus Pulmonary artery The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings (Select all that apply.) Carbon monoxide inhalation Hypothermic fingers Intravascular dyes Nail polish Jaundice The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors (Select all that apply.) Obesity Cigarette smoking Heavy alcohol intake The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment (Select all that apply.) Patients can actively participate in their treatment. Self-monitoring helps with compliance and treatment. Patients can provide information about patterns to health care providers.
A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe