Download Nursing Exam: Vital Signs Assessment Questions and Answers and more Exams Nursing in PDF only on Docsity!
BSN !! 206 !! Hallmark !! Exam !! with !! precise !!
answers
Which !! of !! the !! following !! patients !! would !! require !! follow-up? A !! child !! with !! a !! respiratory !! rate !! of !! 20 !! breaths !! per !! minute. An !! adolescent !! with !! a !! respiratory !! rate !! of !! 16 !! breaths !! per !! minute. A !! newborn !! with !! a !! respiratory !! rate !! of !! 40 !! breaths !! per !! minute. An !! adult !! with !! a !! respiratory !! rate !! of !! 10 !! breaths !! per !! minute. !! - !! correct !! answer✔✔An !! adult !! with !! a !! respiratory !! rate !! of !! 10 !! breaths !! per !! minute Which !! of !! the !! following !! vital !! signs !! recorded !! for !! an !! older !! adult !! would !! be !! considered !! acceptable !! (within !! normal !! limits)? Temp !! 96.8° !! F !! (36 !! °C), !! P-60, !! R-18, !! BP !! 160/90, !! O2 !! sat !! 93%. Temp !! 97.0° !! F !! (36.1 !! °C), !! P-60, !! R-16, !! BP !! 116/78, !! O2 !! sat !! 95%. Temp !! 98.6 !! °F !! (37 !! °C), !! P-56, !! R-20, !! BP !! 120/80, !! O2 !! sat !! 91%. Temp !! 98.0 !! °F !! (36.7 !! °C), !! P-76, !! R-22, !! BP !! 110/70, !! O2 !! sat !! 88% !! - !! correct !! answer✔✔Temp !! 97.0° !! F !! (36.1 !! °C), !! P-60, !! R-16, !! BP !! 116/78, !! O2 !! sat !! 95%. The !! nurse !! has !! delegated !! the !! task !! of !! temperature !! assessment !! to !! the !! NAP. !! Which !! information !! should !! be !! provided !! to !! the !! NAP? !! (Select !! all !! that !! apply.) The !! type !! of !! temperature !! required. The !! patient's !! age. The !! frequency !! for !! taking !! or !! monitoring !! the !! temperature. The !! patient's !! diagnosis. What !! changes !! to !! report !! immediately !! to !! the !! nurse. !! - !! correct !! answer✔✔What !! changes !! to !! report !! immediately !! to !! the !! nurse The !! frequency !! for !! taking !! or !! monitoring !! the !_! temperature
The !! type !! of !! temperature !! required Which !! of !! the !! following !! situations !! may !! affect !! a !! patient's !! vital !! signs? !! (Select !! all !! that !! apply.) Moving !! from !! lying !! to !! standing !! position. Time !! of !! day. Occupation. Isolation !! precautions. Pain !! rated !! as !! a !! 7 !! on !! 0-10 !! pain !! scale. !! - !! correct !! answer✔✔Moving !! from !! lying !! to !! standing !! position Time !! of !! Day Pain !! rated !! as !! a !! 7 !! on !! a !! 0-10 !! pain !! scale 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.) To !! provide !! the !! patient !! with !! reassurance !! that !! he !! or !! she !! is !! being !! cared !! for !! by !! a !! competent !! staff. To !! provide !! a !! set !! of !! vital !! signs !! to !! use !! for !! comparison !! during !! and !! after !! surgery. You !! Answered !! To !! ensure !! the !! equipment !! is !! appropriately !! calibrated !! and !! functional. To !! verify !! the !! patient !! is !! not !! experiencing !! any !! complications !! that !! may !! contraindicate !! surgery !! or !! require !! intervention. You !! Answered !! To !! determine !! whether !! the !! patient !! is !! "feeling !! funny" !! or !! "different". !! - !! correct !! answer✔✔To !! provide !! a !! set !! of !! vital !! signs !! to !! use !! for !! comparison !! during !! and !! after !! surgery To !! verify !! the !! patient !! is !! not !! experiencing !! any !! complications !! that !! may !! contraindicate !! surgery !! or !! require !! intervention 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?
"Ask !! the !! patient !! not !! to !! eat, !! drink, !! or !! smoke !! for !! 20 !! minutes !! and !! then !! assess !! the !! patient's !! oral !! temperature." !! - !! correct !! answer✔✔Ask !! the !! patient !! to !! not !! eat, !! drink, !! or !! smoke !! for !! 20 !! minutes !! then !! assess !! the !! patient's !! oral !! temperature For !! which !! patient !! would !! a !! tympanic !! thermometer !! be !! the !! preferred !! thermometer !! to !! use? A !! marathon !! runner !! who !! developed !! weakness !! during !! the !! race. A !! tachypneic !! patient !! who !! is !! receiving !! oxygen !! by !! nasal !! cannula. A !! pediatric !! patient !! who !! had !! tubes !! surgically !! placed !! in !! the !! ears. A !! newborn !! that !! requires !! continuous !! temperature !! monitoring. !! - !! correct !! answer✔✔A !! tachypneic !! patient !! who !! is !! receiving !! oxygen !! by !! nasal !! cannula Which !! of !! the !! following !! patients !! would !! require !! frequent !! assessment !! of !! their !! temperature? !! (Select !! all !! that !! apply.) A !! young !! adult !! with !! a !! white !! blood !! count !! of !! 15,000/mm3. An !! adult !! female !! in !! the !! recovery !! room !! following !! a !! hysterectomy. A !! patient !! receiving !! a !! blood !! transfusion !! for !! chronic !! anemia. A !! child !! who !! is !! below !! the !! normal !! height !! and !! weight !! for !! his !! age. An !! elderly !! patient !! who !! needs !! assistance !! with !! feeding !! and !! dressing. !! - !! correct !! answer✔✔A !! young !! adult !! with !! a !! white !! blood !! count !! of !! 15,000/mm An !! adult !! female !! in !! the !! recovery !! room !! following !! a !! hysterectomy A !! patient !! receiving !! a !! blood !! transfusion !! for !! chronic !! anemia 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.) Remove !! the !! patient's !! blankets. Limit !! the !! patient's !! fluid !! intake. Apply !! a !! hyperthermia !! blanket !! as !! ordered. Administer !! an !! antipyretic !! to !! the !! patient !! as !! ordered.
Place !! the !! patient's !! feet !! in !! a !! tub !! of !! cool !! water !! with !! ice. !! - !! correct !! answer✔✔Remove !! the !! patient's !! blankets Administer !! an !! antipyretic !! to !! the !! patient !! as !! ordered Which !! of !! the !! following !! actions, !! if !! made !! by !! the !! NAP, !! would !! require !! intervention !! and !! further !! instruction !! by !! the !! nurse? !! (Select !! all !! that !! apply.) The !! NAP !! uses !! a !! blue-tipped !! electronic !! probe !! for !! assessing !! a !! patient's !! axillary !! temperature. The !! NAP !! wipes !! the !! single-use !! chemical !! dot !! thermometer !! and !! places !! it !! back !! in !! the !! patient's !! drawer !! for !! future !! use. The !! NAP !! inserts !! the !! red-tipped !! electronic !! thermometer !! probe !! into !! the !! patient's !! mouth !! after !! applying !! a !! probe !! cover. The !! NAP !! pulls !! the !! pinna !! up, !! back, !! and !! out !! in !! an !! adult !! when !! inserting !! the !! tympanic !! thermometer. The !! NAP !! waits !! un !! - !! correct !! answer✔✔The !! NAP !! wipes !! the !! single-use !! chemical !! dot !! thermometer !! and !! places !! it !! back !! in !! the !! patient's !! drawer !! for !! future !! use The !! NAP !! inserts !! the !! red=tipped !! electronic !! thermometer !! probe !! into !! the !! patient's !! mouth !! after !! applying !! a !! probe !! cover Identify !! the !! factors !! that !! may !! have !! an !! effect !! on !! an !! elderly !! patient's !! temperature: !! (Select !! all !! that !! apply.) Participation !! in !! physical !! therapy !! exercises. Room !! temperature. Drinking !! a !! cold !! glass !! of !! water. Patient's !! height. Infection. !! - !! correct !! answer✔✔Participation !! in !! physical !! therapy !! exercises room !! temperature drinking !! a !! cold !! glass !! of !! water infection
The !! patient !! who !! was !! just !! informed !! of !! a !! diagnosis !! of !! cancer. An !! elderly !! patient !! with !! Type !! 1 !! diabetes !! who !! is !! otherwise !! healthy. A !! patient !! who !! is !! receiving !! bolus !! IV !! fluids. A !! patient !! with !! Alzheimer's !! disease. A !! patient !! with !! peripheral !! vascular !! disease. !! - !! correct !! answer✔✔The !! patient !! who !! was !! just !! informed !! of !! a !! diagnosis !! of !! cancer A !! patient !! who !! is !! receiving !! bolus !! IV !! fluids A !! patient !! with !! peripheral !! vascular !! disease Whenever !! there !! is !! an !! alteration !! in !! the !! radial !! pulse !! rate, !! rhythm, !! or !! amplitude, !! the !! nurse !! should !! initially !! do !! which !! of !! the !! following? Reassess !! the !! radial !! pulse !! for !! 30 !! seconds. Auscultate !! the !! apical !! pulse !! for !! quality !! and !! rate. Check !! the !! carotid !! pulses !! one !! side !! at !! a !! time. Check !! the !! radial !! pulse !! on !! the !! opposite !! side. !! - !! correct !! answer✔✔Auscultate !! the !! apical !! pulse !! for !! quality !! and !! rate What !! is !! the !! normal !! pulse !! range !! for !! an !! adult? 90 !! to !! 140 !! beats !! per !! minute. 50 !! to !! 80 !! beats !! per !! minute. 120 !! to !! 160 !! beats !! per !! minute. 60 !! to !! 100 !! beats !! per !! minute. !! - !! correct !! answer✔✔ 60 !! to !! 100 !! beats !! per !! minute The !! nurse !! should !! routinely !! auscultate !! the !! apical !! pulse !! with !! the !! bell !! side !! of !! the !! stethoscope, !! and !! use !! the !! diaphragm !! side !! to !! identify !! heart !! murmurs. False. True. !! - !! correct !! answer✔✔False
In !! which !! of !! the !! following !! patients !! would !! the !! nurse !! expect !! to !! find !! a !! decrease !! in !! pulse !! rate? !! (Select !! all !! that !! apply.) A !! patient !! who !! received !! morphine !! for !! pain. A !! student !! who !! is !! getting !! ready !! to !! take !! an !! exam. A !! patient !! returning !! from !! the !! operating !! room. A !! patient !! who !! experienced !! a !! bleeding !! episode. A !! newborn !! following !! a !! heelstick. !! - !! correct !! answer✔✔A !! patient !! who !! received !! morphine !! for !! pain A !! patient !! returning !! from !! the !! operating !! room 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.) The !! NAP !! assessed !! the !! patient's !! BP !! before !! taking !! the !! patient's !! pulse. The !! NAP !! is !! assessing !! for !! a !! pulse !! on !! the !! thumb !! side !! of !! the !! wrist. The !! NAP !! is !! assessing !! for !! a !! pulse !! on !! the !! ulnar !! side !! of !! the !! wrist. The !! patient !! was !! previously !! reported !! to !! have !! a !! full, !! bounding !! pulse. The !! NAP !! is !! pressing !! down !! too !! hard !! on !! the !! patient's !! radial !! site. The !! NAP !! failed !! to !! auscultate !! the !! patient's !! wrist !! with !! a !! stethoscope. !! - !! correct !! answer✔✔The !! NAP !! is !! assessing !! for !! a !! pulse !! on !! the !! ulnar !! side !! of !! the !! wrist The !! NAP !! is !! pressing !! down !! too !! hard !! on !! the !! patient's !! radial !! site What !! is !! an !! appropriate !! nursing !! intervention !! for !! an !! adult !! patient !! with !! a !! respiratory !! rate !! of !! 30 !! breaths !! per !! minute? !! (Select !! all !! that !! apply.) Tell !! the !! patient !! their !! breaths !! are !! being !! counted !! so !! the !! patient !! will !! breathe !! slower. Count !! the !! respiratory !! rate !! again !! for !! a !! full !! 60 !! seconds !! (1 !! minute). Assess !! physiologic !! factors !! that !! may !! be !! causing !! the !! patient !! to !! breathe !! so !! fast. Administer !! a !! bronchodilator !! that !! will !! decrease !! the !! respiratory !_! rate.
Inform !! the !! patient !! when !! monitoring !! his !! or !! her !! respirations. Correct! !! Continue !! to !! act !! as !! though !! taking !! the !! patient's !! pulse !! while !! discretely !! observing !! the !! rise !! and !! fall !! of !! the !! patient's !! chest. Assess !! the !! respirations !! while !! the !! patient !! is !! talking. Auscultate !! the !! lung !! sounds, !! asking !! the !! patient !! to !! take !! a !! deep !! breath !! in !! through !! the !! nose !! and !! exhale !! slowly !! through !! the !! mouth. !! - !! correct !! answer✔✔Continue !! to !! act !! as !! though !! taking !! the !! patient's !! pulse !! while !! discretely !! observing !! the !! rise !! and !! fall !! of !! the !! patient's !! chest 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? 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. When !! the !! patient's !! respiratory !! rate !! is !! irregular, !! the !! NAP !! counts !! the !! patient's !! respirations !! for !! 1 !! full !! minute. 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. 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. !! - !! correct !! answer✔✔When !! a !! patient !! inhales !! a !! breath, !! the !! NAP !! counts !! that !! as !! one, !! and !! when !! the !! patients !! exhales !! a !! breath, !! the !! NAP !! counts !! that !! as !! two The !! nurse !! assesses !! the !! BP !! in !! both !! arms !! of !! a !! newly !! admitted !! patient. !! Why !! would !! the !! nurse !! do !! this? To !! practice !! the !! technique !! of !! blood !! pressure !! measurement. To !! determine !! if !! there !! is !! a !! difference !! in !! the !! readings !! between !! the !! two !! arms. To !! verify !! the !! BP !! reading !! is !! 10 !! mm !! Hg !! higher !! in !! the !! dominant !! arm. To !! assess !! for !! a !! pulse !! deficit !! and !! record !! this !! as !! a !! baseline !! measurement. !! - !! correct !! answer✔✔To !! determine !! if !! there !! is !! a !! difference !! in !! the !! readings !! between !! the !! two !_! arms
Which !! of !! the !! following !! patients !! would !! be !! considered !! hypertensive !! after !! having !! two !! or !! more !! consistent !! readings !! of !! these !! values? An !! African-American !! patient !! with !! a !! systolic !! BP !! of !! 100. A !! football !! player !! with !! a !! diastolic !! BP !! of !! 94. An !! elderly !! patient !! with !! a !! systolic !! BP !! of !! 88. A !! pregnant !! woman !! with !! a !! diastolic !! BP !! of !! 67. !! - !! correct !! answer✔✔A !! football !! player !! with !! a !! diastolic !! BP !! of !! 94 For !! which !! patient !! should !! you !! avoid !! using !! a !! leg !! pressure !! cuff !! (thigh !! cuff) !! to !! assess !! BP? A !! patient !! who !! is !! a !! double !! arm !! amputee !! following !! a !! motor !! vehicle !! accident. A !! patient !! with !! a !! deep !! vein !! thrombosis !! (blood !! clot, !! usually !! in !! the !! lower !! extremities). A !! patient !! with !! a !! history !! of !! a !! right-sided !! cerebrovascular !! accident !! (stroke). A !! patient !! with !! an !! arteriovenous !! shunt !! located !! in !! the !! forearm !! for !! hemodialysis. !! - !! correct !! answer✔✔A !! patient !! with !! a !! deep !! vein !! thrombosis !! (blood !! clot, !! usually !! in !! the !! lower !! extremities) The !! student !! nurse !! is !! unsure !! of !! the !! BP !! measurement. !! What !! should !! the !! student !! nurse !! do !! first? Wait !! 30 !! seconds !! and !! repeat !! the !! measurement !! on !! the !! same !! arm. Assess !! the !! BP !! in !! the !! other !! arm. Get !! the !! nurse !! to !! assess !! the !! BP. Determine !! if !! the !! patient !! received !! an !! antihypertensive !! medication. !! - !! correct !! answer✔✔Assess !! the !! BP !! in !! the !! other !! arm Using !! the !! image !! below, !! please !! choose !! the !! correct !! BP !! combination:<IM !! src="http://www.coursewareobjects.com/objects/nso3e_v1/images/assessment_images/ mod1l5q5.gif" Link !! (Links !! to !! an !! external !! site.you !! may !! need !! to !! right !! click !! this !! link !! for !! it !! to !! open). Image !! A !! = !! 126/76, !! Image !! B !! = !! 140/90, !! Image !! C !! = !! 138/84, !! Image !! D !! = !! 120/
The !! NAP !! reports !! to !! the !! nurse !! the !! patient's !! respirations !! are !! 32 !! and !! the !! patient !! is !! complaining !! of !! shortness !! of !! breath. !! What !! is !! the !! best !! action !! by !! the !! nurse !! at !! this !! time? Request !! the !! NAP !! obtain !! the !! patient's !! pulse !! oximetry !! and !! report !! back. Ask !! the !! NAP !! to !! obtain !! and !! document !! a !! full !! set !! of !! vital !! signs. Assess !! the !! patient, !! including !! the !! pulse !! oximetry !! reading. Notify !! the !! health !! care !! provider !! of !! this !! change !! in !! condition. !! - !! correct !! answer✔✔Assess !! the !! patient, !! including !! the !! pulse !! oximetry !! reading Which !! patient !! is !! at !! high !! risk !! for !! for !! the !! pulse !! oximetry !! alarm !! to !! sound? A !! patient !! with !! a !! continuous !! pulse !! oximetry !! reading !! of !! 84%. A !! patient !! who !! is !! receiving !! oxygen !! via !! face !! mask. A !! patient !! who !! has !! an !! intermittent !! pulse !! oximetry !! reading !! of !! 95%. A !! patient !! with !! a !! heart !! rate !! of !! 64 !! beats !! per !! minute. !! - !! correct !! answer✔✔A !! patient !! with! ! a !! continuous !! pulse !! oximetry !! reading !! of !! 84% A !! patient !! complains !! of !! feeling !! excessively !! tired. !! Which !! statement, !! if !! made !! by !! the !! NAP, !! indicates !! further !! instruction !! is !! necessary? "I !! will !! turn !! the !! continuous !! pulse !! oximetry !! alarms !! off !! at !! night !! so !! you !! can !! sleep." "I !! can !! give !! you !! a !! back !! massage !! to !! help !! you !! relax !! before !! bedtime." "If !! the !! finger !! clip !! is !! bothering !! you, !! I !! can !! attach !! a !! probe !! to !! your !! ear." "I !! will !! notify !! the !! nurse !! that !! you !! need !! your !! sleeping !! medication !! tonight." !! - !! correct !! answer✔✔I !! will !! turn !! the !! continuous !! pulse !! oximetry !! alarms !! off !! at !! night !! so !! you !! can !! sleep. The !! NAP !! tells !! the !! nurse !! the !! patient's !! pulse !! oximetry !! is !! 85% !! on !! room !! air. !! What !! nursing !! action(s) !! should !! the !! nurse !! take? !! (Select !! all !! that !! apply.) Start !! oxygen !! at !! 2 !! liters !! per !! minute !! by !! nasal !! cannula. Reassess !! the !! patient's !! pulse !_! oximetry.
Place !! the !! patient !! in !! the !! high-Fowler's !! position. Have !! the !! NAP !! take !! the !! patient's !! vital !! signs. Assess !! the !! patient's !! respiratory !! and !! cardiac !! status. !! - !! correct !! answer✔✔Reassess !! the !! patient's !! pulse !! oximetry Place !! the !! patient !! in !! the !! high-Fowler's !! position Assess !! the !! patient's !! respiratory !! and !! cardiac !! status The !! nurse !! reads !! the !! following !! entry !! in !! a !! patient's !! health !! record. !! The !! patient !! has !! an !! order !! for !! SpO2 !! every !! 4 !! hours. !! Based !! on !! this !! information, !! what !! would !! be !! the !! nurse's !! best !! action?01/25/17 !! 0800 !! Unable !! to !! obtain !! pulse !! oximetry !! reading. !! Attempted !! X2 !! fingers !! of !! each !! hand. !! Patient's !! fingers !! cool !! to !! touch. !! Patient !! states !! has !! artificial !! nails. !! Patient !! on !! 2 !! L !! oxygen !! per !! nasal !! cannula. !! Respirations !! nonlabored. !! C. !! Smith, !! N.A.P._ Remove !! one !! of !! the !! patient's !! acrylic !! nails !! and !! reattempt !! obtaining !! the !! SpO2. Place !! the !! patient's !! hands !! under !! warm !! running !! water !! and !! reattempt !! the !! reading. Have !! the !! NAP !! use !! a !! different !! site, !! such !! as !! the !! ear !! lobe, !! to !! obtain !! the !! SpO2 !! reading. Nothing !! further, !! as !! the !! NAP !! has !! provided !! sufficient !! data !! regarding !! patient !! condition. !!
- !! correct !! answer✔✔Have !! the !! NAP !! use !! a !! different !! site, !! such !! as !! the !! ear !! lobe, !! to !! obtain !! the !! SpO2 !! reading. Which !! of !! the !! following !! vital !! signs !! are !! expected !! for !! the !! adult !! patient !! who !! has !! problems! ! in !! oxygenation? Temp !! 97.5° !! F !! (36.4 !! °C), !! P-76, !! R-20, !! BP !! 110/70, !! O2 !! sat !! 95%. Temp !! 98.2° !! F !! (36.8 !! °C), !! P-64, !! R-16, !! BP !! 120/80, !! O2 !! sat !! 96%. Temp !! 98.6° !! F !! (37 !! °C), !! P-102, !! R-28, !! BP !! 98/50, !! O2 !! sat !! 85%. Temp !! 97.9° !! F !! (36.6 !! °C), !! P-80, !! R-18, !! BP !! 140/90, !! O2 !! sat !! 95%. !! - !! correct !! answer✔✔Temp !! 98.6° !! F !! (37 !! °C), !! 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 !! these !! can !! be !! delegated !! to !! NAP? !! (Select !! all !! that !_! apply.)
The !! ventricles !! during !! contraction. The !! pulse !! pressure. The !! ventricles !! during !! relaxation. The !! systolic !! pressure. The !! diastolic !! pressure. The !! pulse !! deficit. !! - !! correct !! answer✔✔The !! ventricles !! during !! relaxation The !! diastolic !! pressure The !! nurse !! is !! having !! great !! difficulty !! hearing !! any !! sound !! when !! taking !! a !! patient's !! BP. !! What !! can !! the !! nurse !! do !! to !! increase !! the !! ability !! to !! auscultate !! the !! reading? !! (Select !! all !! that !! apply.) Ensure !! the !! bladder !! of !! the !! cuff !! is !! centered !! 1 !! inch !! (2.5 !! cm) !! above !! the !! brachial !! artery. Make !! sure !! the !! stethoscope !! does !! not !! touch !! the !! patient's !! clothing !! or !! BP !! cuff. Use !! the !! bell !! side !! of !! the !! stethoscope !! to !! auscultate !! the !! blood !! pressure. Use !! a !! different !! stethoscope !! with !! longer !! tubing !! for !! improved !! conduction !! of !! sound. Reduce !! environmental !! noise !! by !! turning !! off !! the !! TV !! or !! closing !! the !! door. Keep !! the !! stethoscope !! tubing !! still !! to !! avoid !! extraneous !! sound. Ensure !! the !! chest !! piece !! is !! rotated !! to !! the !! diaphragm !! side. !! - !! correct !! answer✔✔Ensure !! the !! bladder !! of !! the !! cuff !! is !! centered !! 1 !! inch !! (2.5cm) !! above !! the !! brachial !! artery Make !! sure !! the !! stethoscope !! does !! not !! touch !! the !! patient's !! clothing !! or !! BP !! cuff Reduce !! environmental !! noise !! by !! turning !! off !! the !! TV !! or !! closing !! the !! door Keep !! the !! stethoscope !! tubing !! still !! to !! avoid !! extraneous !! sound Ensure !! the !! chest !! piece !! is !! rotated !! to !! the !! diaphragm !! side The !! NAP !! reports !! to !! the !! nurse !! that !! the !! patient's !! pulse !! oximetry !! is !! 88%. !! What !! action(s) !! should !! the !! nurse !! take? !! (Select !! all !! that !! apply.) Verify !! the !! reading !! by !! taking !! the !! patient's !! pulse !! oximetry. Notify !! the !! health !! care !! provider.
Perform !! a !! cardiopulmonary !! assessment. None !! should !! be !! taken !! because !! this !! is !! a !! normal !! value. Assist !! the !! patient !! to !! a !! high-Fowler's !! position. Assist !! the !! patient !! to !! a !! fully !! supine !! position. Be !! prepared !! to !! administer !! oxygen. !! - !! correct !! answer✔✔Verify !! the !! reading !! by !! taking !! the !! patient's !! pulse !! oximetry Notify !! the !! health !! care !! provider Perform !! a !! cardiopulmonary !! assessment Assist !! the !! patient !! to !! a !! high-Fowler's !! position Be !! prepared !! to !! administer !! oxygen A !! 15-year-old !! male !! patient !! is !! hypothermic. !! Which !! temperature !! reflects !! hypothermia? 99° !! F !! (37.2°C). 95° !! F !! (35°C). 110° !! F !! (43.3°C). 101° !! F !! (38.3°C). !! - !! correct !! answer✔✔95F !! (35C) Identify !! why !! a !! child's !! respirations !! might !! be !! shallow. The !! child !! was !! running !! around !! in !! the !! waiting !! room !! with !! her !! sibling !! before !! her !! name !! was !! called. The !! child's !! parents !! are !! smokers !! and !! the !! lungs !! are !! negatively !! affected !! by !! secondhand !! smoke. The !! child !! is !! in !! acute !! pain. The !! child !! is !! anxious !! about !! seeing !! the !! doctor. !! - !! correct !! answer✔✔The !! child !! is !! in !! acute !! pain You !! are !! taking !! a !! patient's !! BP !! by !! using !! the !! one-step !! method. !! Which !! of !! the !! following !! is !! an !! incorrect !! step !! in !! the !! sequence !! for !! performing !! this !_! procedure?
Who !! would !! the !! nurse !! expect !! to !! have !! the !! highest !! body !! temperature !! reading? An !! elderly !! African-American !! male. An !! adult !! female !! who !! is !! walking. A !! preterm !! baby !! who !! is !! sleeping. A !! teenager !! playing !! video !! games. !! - !! correct !! answer✔✔An !! adult !! female !! who !! is !! walking Which !! of !! the !! following !! should !! the !! nurse !! report !! to !! the !! health !! care !! provider? An !! elderly !! male !! with !! a !! temperature !! of !! 96.8°F !! (36°C). A !! young !! adult !! with !! a !! blood !! pressure !! of !! 110/70. An !! adult !! patient !! with !! a !! heart !! rate !! of !! 55. A !! newborn !! with !! a !! respiratory !! rate !! of !! 40. !! - !! correct !! answer✔✔An !! adult !! patient !! with !! a !! heart !! rate !! of !! 55 A !! 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? 98.6°F !! (37°C), !! 84, !! 20, !! 120/ 97.8°F !! (36.5°C), !! 110, !! 24, !! 80/ 99.0°F !! (37.2°C), !! 88, !! 16, !! 130/ 100.4°F !! (38°C), !! 76, !! 24, !! 140/90 !! - !! correct !! answer✔✔97.8°F !! (36.5°C), !! 110, !! 24, !! 80/ The !! nurse !! was !! assigned !! to !! care !! for !! five !! patients. !! Which !! of !! the !! following !! vital !! sign !! measurements !! would !! be !! cause !! for !! concern? !! (Select !! all !! that !! apply.) Correct! !! 65-year-old !! with !! blood !! pressure !! of !! 140/ 22-year-old !! with !! heart !! rate !! of !! 90 !! beats/minute 75-year-old !! with !! pulse !! oximetry !! of !! 88% !! on !! room !! air 88-year-old !! with !! temperature !! of !! 96.8° !! F !! (36° !_! F)
8-year-old !! with !! respiratory !! rate !! of !! 24 !! breaths/minute !! - !! correct !! answer✔✔75-year-old !! with !! pulse !! oximetry !! of !! 88% !! on !! room !! air The !! nurse !! reads !! the !! following !! nurse's !! note !! in !! the !! patient's !! health !! record. !! What !! is !! the !! priority !! nursing !! intervention !! based !! on !! this !! information?9/21/17 !! 1800 !! Patient !! complains !! of !! headaches, !! almost !! daily, !! occurring !! more !! frequently !! in !! the !! evening. !! BP !! 164/98. !! P. !! Johnson !! N.A.P. Inform !! the !! patient !! it !! is !! normal !! to !! have !! a !! higher !! BP !! reading !! in !! the !! evening. Administer !! acetaminophen !! (Tylenol) !! to !! relieve !! the !! patient's !! headache. Instruct !! the !! NAP !! to !! repeat !! the !! BP !! measurement !! using !! a !! manual !! cuff. Obtain !! a !! complete !! set !! of !! vital !! signs !! and !! gather !! further !! assessment !! data. !! - !! correct !! answer✔✔Obtain !! a !! complete !! set !! of !! vital !! signs !! and !! gather !! further !! assessment !! data A !! nursing !! student !! is !! assigned !! to !! take !! the !! vital !! signs !! on !! a !! patient !! and !! finds !! the !! radial !! pulse !! to !! be !! irregular. !! What !! action !! should !! the !! nursing !! student !! take? Check !! the !! patient's !! previous !! pulse !! reading. Wait !! 15 !! minutes !! and !! reassess !! the !! pulse. Auscultate !! the !! patient's !! apical !! pulse. Ask !! a !! fellow !! student !! to !! assess !! the !! pulse. !! - !! correct !! answer✔✔Auscultate !! the !! patient's !! apical !! pulse An !! elderly !! patient !! was !! recently !! admitted !! to !! a !! medical !! unit !! with !! severe !! fluid !! and !! electrolyte !! imbalance. !! His !! family !! states !! that !! he !! has !! periods !! of !! confusion. !! What !! are !! some !! practical !! precautions !! the !! nurse !! can !! take !! to !! ensure !! the !! patient's !! safety !! without !! having !! to !! use !! restraints? !! (Select !! all !! that !! apply.) Use !! a !! security !! camera !! to !! monitor !! the !! patient !! while !! in !! bed. Make !! staff !! assignments !! for !! patients !! in !! adjacent !! rooms. Activate !! the !! bed !! alarm !! when !! the !! patient !! is !! in !! bed. Perform !! nurse !! toilet !! and !! turn !! or !! comfort !! and !! safety !! rounds !! hourly.
