(NGN)NCLEX NGN RN EXAM 2024-2025(VERSION 3) ACTUAL EXAM QUESTIONS WITH CORRECT DETAILED AN, Exercises of Nursing

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(NGN)NCLEX NGN RN EXAM 2024- 2025 (VERSION 3)

ACTUAL EXAM QUESTIONS WITH CORRECT

DETAILED AND VERIFIED ANSWERS WITH

RATIONALES A+GRADE

A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature? a. Febrile b. Hypothermia c. Hypertension d. Afebrile - ANSWER>d. Afebrile means without fever. RATIONALE: This temperature is within the normal range for an adult. Fever (pyrexia) is an elevation of body temperature; a person with fever is said to be febrile. Hypothermia is a low body temperature and hyperthermia is a high body temperature. A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? a. Readminister the medication and notify the primary care provider. b. Readminister the pill in a liquid form if possible. c. Assess the vomit, looking for the pill. d. Notify the primary care provider. - ANSWER> c. RATIONALE: If a patient vomits immediately after swallowing an oral pill, the nurse should assess the vomit for the pill or fragments of it. The nurse should then notify the primary care provider to see if another dosage should be administered.

A nurse is administering an oral medication to a patient via a gastric tube. The nurse observes the medication enter the tube, and then the tube becomes clogged. What would be the appropriate initial action of the nurse in this situation? a. Attempt to dislodge the medication with a 10 - mL syringe. b. Notify the primary care provider. c. Remove the tube and replace it with another tube. d. Flush the tube with 60 mL of water. - ANSWER> a. RATIONALE:If medication becomes clogged in a gastric tube, the nurse should attach a 10-mL syringe on the end of the tube and pull back and lightly apply pressure to the plunger in a repetitive motion to attempt to dislodge the medication. If the medication does not move through the tube, the nurse should notify the primary care provider, who may request the tube be replaced. A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. a. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. b. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. c. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. d. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. e. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption.

f. Excretion is the process of removing a drug, or its metabolites (products of metabolis - ANSWER>a, d, f. RATIONALE: Distribution occurs after a drug has been absorbed into the bloodstream and the drug is distributed throughout the body, becoming available to body fluids and body tissues. Some drugs move from the intestinal lumen to the liver by way of the portal vein and do not go directly into the systemic circulation following oral absorption. This is called the first-pass effect, or hepatic first pass. Excretion is the process of removing a drug or its metabolites (products of metabolism) from the body. Absorption is the process by which a drug is transferred from its site of entry into the body to the bloodstream. Metabolism, or biotransformation, is the change of a drug from its original form to a new form. The liver is the primary site for drug metabolism. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug excretion. A nurse is reconstituting powdered medication in a vial. Which action is a recommended step in this process? a. The nurse draws up the proper amount of powered medication into the syringe. b. The nurse inserts the needle through the rubber stopper of the diluent vial. c. The nurse gently agitates the powdered medication vial to mix the powder and diluent completely. d. The nurse draws up the prescribed amount of medication while holding the syringe horizontally at eye level. - ANSWER>c. RATIONALE:When reconstituting powdered medication in a vial, the nurse should draw up the appropriate amount of diluent into the syringe, insert the needle through the center of the self-sealing stopper on the powdered medication vial, inject the diluent into the powdered medication vial, remove the needle from the vial and replace the cap, and

gently agitate the vial to mix the powdered medication and diluent completely. The nurse should then draw up the prescribed amount of medication while holding the syringe vertically and at eye level. A medication order reads: "K-Dur, 20 mEq po b.i.d." When and how does the nurse correctly give this drug? a. Daily at bedtime by subcutaneous route b. Every other day by mouth c. Twice a day by the oral route d. Once a week by transdermal patch - ANSWER>c. RATIONALE:The abbreviation "b.i.d." refers to twice-a-day administration. po (by mouth) refers to administration by the oral route. A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. a. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b. Some people experience the same response with a placebo as with the active drug used in studies. c. People with liver disease metabolize drugs more quickly than people with normal liver functioning. d. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. e. Oral medications should not be given with food as the food may delay the absorption of the medications.

f. Circadian rhythms and cycles may influence drug action. - ANSWER>a, b, d, f. Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patient's expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patient's environment may also influence the patient's response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods. A physician orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? a. A single dose during the postoperative period b. Doses administered as needed for pain relief c. One dose administered immediately d. Doses routinely administered as a standing order - ANSWER>b. RATIONALE: When the prescriber writes a PRN order ("as needed") for medication, the patient receives medication when it is requested or required. With a single or one-time order, the directive is carried out only once, at a time specified by the prescriber. A stat order is a single order carried out immediately. A standing order (or routine order) is carried out as specified until it is canceled by another order.

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies his identity by: a. Asking the patient his name b. Reading the patient's name on the sign over the bed c. Asking the patient's roommate to verify his name d. Asking, "Are you Mr. Brown?" - ANSWER>a. The nurse should ask the patient to state his name. A sign over the patient's bed may not always be current. The roommate is an unsafe source of information. The patient may not hear his name but may reply in the affirmative anyway (e.g., a person with a hearing deficit). The nurse is administering a medication to a patient via a nasogastric tube. Which are accurate guidelines related to this procedure? Select all that apply. a. Crush the enteric-coated pill for mixing in a liquid. b. Flush open the tube with 60 mL of very warm water. c. Check for proper placement of the nasogastric tube. d. Give each medication separately and flush with water between each drug. e. Lower the head of the bed to prevent reflux. f. Adjust the amount of water used if patient's fluid intake is restricted. - ANSWER>c, d, f. The nurse should use the recommended procedure for checking tube placement prior to administering medications. The nurse should also give each medication separately and flush with water between each drug and adjust the amount of water used if fluids are restricted. Enteric-coated medications should not be crushed, the tube should be flushed with 15 to 30 mL of water, and the head of the bed should be elevated to prevent reflux.

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. Which nursing action is correct? a. Give all the medication in the cartridge because it expanded when it was mixed. b. Call the pharmacy and request the proper dose. c. Refuse to give the medication. d. Dispose of 0.2 mL correctly before administering the drug. - ANSWER>d. Many cartridges are overfilled, and some of the medication needs to be discarded. Always check the volume needed to provide the correct dose with the volume in the syringe. Giving the excess medication in the cartridge may result in adverse effects for the patient. For this dose, it is not necessary to call the pharmacy or refuse to give the medication, provided the order is written correctly. A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. b. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. c. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. d. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin. - ANSWER>b. Regular or short-acting insulin should never be contaminated with NPH

or any insulin modified with added protein. Placing air in the NPH vial first without allowing the needle to contact the solution ensures that the regular insulin will not be contaminated. Ms. Hall has an order for hydromorphone (Dilaudid), 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to Dilaudid. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? a. Administer the medication; the doctor is responsible for medication administration. b. Call Dr. Long and ask that she change the medication. c. Ask the supervisor to administer the medication. d. Ask the pharmacist to provide a medication to take the place of Dilaudid. - ANSWER>b. The nurse is responsible for any medications he or she gives and must contact the doctor to inform her of the patient's allergy to the drug. The nurse should not give the medication and might speak with the supervisor only if uncomfortable with the physician's answer once she is notified. The nurse is legally unable to order a replacement medication, as is the pharmacist. A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? a. Aspirate before giving and gently massage after the injection. b. Do not aspirate; massage the site for 1 minute. c. Do not aspirate before or massage after the injection. d. Massage the site of the injection; aspiration is not necessary but will do no harm. - ANSWER>c. When giving heparin subcutaneously, the nurse should not aspirate or massage, so as not to cause trauma or bleeding in the tissues.

A nurse discovers that she made a medication error. What should be the nurse's first response? a. Record the error on the medication sheet. b. Notify the physician regarding course of action. c. Check the patient's condition to note any possible effect of the error. d. Complete an incident report, explaining how the mistake was made. - ANSWER>c. The nurse's first responsibility is the patient—careful observation is necessary to assess for any effect of the medication error. The other nursing actions are pertinent, but only after checking the patient's welfare. A nurse is teaching an adolescent patient how to use a meter-dosed inhaler to control his asthma. What are appropriate guidelines for this procedure? Select all that apply. a. Remove the mouthpiece cover and shake the inhaler well. b. Take shallow breaths when breathing through the spacer. c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply. d. After inhaling, exhale quickly through pursed lips. e. Wait 1 to 5 minutes as prescribed before administering the next puff. f. Gargle and rinse with salt water after using the MDI. - ANSWER>a, c, e. The correct procedure for using a meter-dosed inhaler is: remove the mouthpiece cover and shake

the inhaler well; breathe normally through the spacer; depress the canister releasing one puff into the spacer and inhale slowly and deeply; after inhaling, hold breath for 5 to 10 seconds, or as long as possible, and then exhale slowly through pursed lips; wait 1 to 5 minutes as prescribed before administering the next puff; and gargle and rinse with tap water after using the MDI. Metoprolol (Lopressor), 25 mg PO, is ordered. Metoprolol is available as 50 - mg tablets. How many tablets would the nurse administer? - ANSWER>1 tablet Phenytoin (Dilantin), 100 mg PO, is ordered to be given through a nasogastric tube. Phenytoin is available as 30 mg/5 mL. How much would the nurse administer? - ANSWER>17 mL Captopril (Capoten), 12.5 mg PO, is ordered. Captopril is available as 25 - mg tablets. How many tablets would the nurse administer? - ANSWER>1/2 tablet Potassium chloride (K-Dur), 20 mEq, is ordered. Potassium chloride is available as 10 mEq per tablet. How many tablets would the nurse administer? - ANSWER> 2 tablets Digoxin (Lanoxin), 0.0625 mg PO, is ordered. Digoxin is available as 0.125-mg tablets. How many tablets would the nurse administer? - ANSWER>1/2 tablet Propantheline bromide (Pro-Banthine), 15 mg, is ordered. Propantheline bromide is available as 7.5-mg tablets. How many tablets would the nurse administer? - ANSWER>2 tablets Ciprofloxacin (Cipro), 500 mg PO, is ordered. Ciprofloxacin is available as 250 - mg

tablets. How many tablets would the nurse administer? - ANSWER>2 tablets Furosemide (Lasix), 20 mg PO, is ordered. Furosemide is available as 40 - mg tablets. How many tablets would the nurse administer? - ANSWER>2 tablets Theophylline elixir, 100 mg PO, is ordered by way of a percutaneous endoscopic gastrostomy tube. Theophylline elixir is available as 80 mg/15 mL. How much would the nurse administer? - ANSWER>19 mL Clonidine (Catapres), 0.1 mg PO, is ordered. Clonidine is available as 0.2-mg tablets. How many tablets would the nurse administer? - ANSWER>1/2 tablet Vitamin K, 10 mg given IM, is ordered. Vitamin K is available as 5 mg/mL. How much would the nurse administer? - ANSWER>2 mL Morphine sulfate 10 mg IV is ordered. Morphine is available as 4 mg/mL. How much would the nurse administer? - ANSWER>2.5 mL Midazolam (Versed), 3 mg IM, is ordered. Midazolam is available as 5 mg/mL. How much would the nurse administer? - ANSWER>4.5 mg Ondansetron (Zofran) 0.15 mg/kg is ordered. Ondansetron is available as 2 mg/mL. The patient weighs 30 kg. How much would the nurse administer? - ANSWER>2.25 mL Epoetin alfa (Epogen), 2,000 units SC, is ordered. Epoetin alfa is available as 4,

units/mL. How much would the nurse administer? - ANSWER>1/2 mL Nalbuphine (Nubain), 1.5 mg IM, is ordered. Nalbuphine is available as 1 mg/mL. How much would the nurse administer? - ANSWER>1.5 mL Octreotide acetate (Sandostatin), 50 mcg SC, is ordered. Octreotide is available as 100 mcg/mL. How much would the nurse administer? - ANSWER>1/2 mL Lisinopril (Zestril) 40 mg once a day is ordered. Zestril is available as an oral solution 8 mg/mL. How much should the nurse administer via the enteral feeding tube? - ANSWER>5 mL Prochlorperazine (Compazine), 7.5 mg IM, is ordered. Prochlorperazine is available as 5 mg/mL. How much would the nurse administer? - ANSWER>1.5 mL Glycopyrrolate (Robinul), 0.4 mg IM, is ordered. Glycopyrrolate is available as 0. mg/mL. How much would the nurse administer? - ANSWER>2 mL Clinical pharmacology is the study of a. the biological effects of chemicals. b. drugs used to treat, prevent, or diagnose disease. c. plant components that can be used as medicines. d. binders and other vehicles for delivering medication. - ANSWER>b Phase I drug studies involve a. the use of laboratory animals to test chemicals. b. patients with the disease the drug is designed to treat.

c. mass marketing surveys of drug effects in large numbers of people. d. healthy human volunteers who are often paid for their participation. - ANSWER>d The generic name of a drug is a. the name assigned to the drug by the pharmaceutical company developing it. b. the chemical name of the drug based on its chemical structure. c. the original name assigned to the drug at the beginning of the evaluation process. d. the name that is often used in advertising campaigns. - ANSWER>a An orphan drug is a drug that a. has failed to go through the approval process. b. is available in a foreign country but not in this country. c. has been tested but is not considered to be financially viable. d. is available without a prescription. - ANSWER>c The FDA pregnancy categories a. indicate a drug's potential or actual teratogenic effects. b. are used for research purposes only. c. list drugs that are more likely to have addicting properties. d. are tightly regulated by the DEA. - ANSWER>a The storing, prescribing, and distributing of controlled substances—drugs that are more apt to be addictive—are monitored by a. the FDA. b. the Department of Commerce. c. the Federal Bureau of Investigation.

d. the DEA. - ANSWER>d Healthy young women are sometimes not able to be involved in phase I studies of drugs because a. male bodies are more predictable and responsive to chemicals. b. females are more apt to suffer problems with ova, which are formed only before birth. c. males can tolerate the unknown adverse effects of many drugs better than females. d. there are no standards to use to evaluate the female response. - ANSWER>b A patient has been taking fluoxetine (Prozac) for several years, but when picking up the prescription this month found that the tablets looked different and became concerned. The nurse, checking with the pharmacist, found that fluoxetine had just become available in the generic form and the prescription had been filled with the generic product. The nurse should tell the patient a. that the new tablet may have similar effects or may not so the patient should carefully monitor response. b. that generic drugs are available without a prescription and they are just as safe as the brand name medication. c. that the law requires that prescriptions be filled with the generic form if available to cut down the cost of medications. d. that the pharmacist filled the prescription with the wrong drug and it should be returned to the pharmacy for a refund. - ANSWER>c When teaching a patient about OTC drugs, which points should the nurse include? a. These drugs are very safe and can be used freely to relieve your complaints. b. These compounds are called drugs, but they aren't really drugs.

c. Some of these drugs were once prescription drugs, but are now thought to be safe when used as directed. d. Reading the label of these drugs is very important; the name of the active ingredient is prominent; you should always check the ingredient name. e. It is important to read the label and to see what the recommended dose of the drug is; some of these drugs can cause serious problems if too much of the drug is taken. f. It is important to report the use of any OTC drug to your health care provider because many of them can interact with drugs that might be prescribed for you. - ANSWER>c, d, e, f A patient asks what generic drugs are and if he should be using them to treat his infection. Which of the following statements should be included in the nurse's explanation? a. A generic drug is a drug that is sold by the name of the ingredient, not the brand name. b. Generic drugs are always the best drugs to use because they are never any different from the familiar brand names. c. Generic drugs are not available until the patent expires on a specific drug. d. Generic drugs are usually cheaper than the well-known brand names, and some insurance companies require that you receive the generic drug if one is available. e. Generic drugs are forms of a drug that are available over the counter and do not require a prescription. f. Your physician may want you to have the brand name of a drug, not the generic form, and DAW will be on your prescription form. g. Generic drugs are less likely to cause adverse effects than bra - ANSWER>a, c, d, f

Chemotherapeutic agents are drugs that a. are used only to treat cancers. b. replace normal body chemicals that are missing because of disease. c. interfere with foreign cell functioning causing cell death, such as invading microorganisms or neoplasms. d. stimulate the normal functioning of a cell. - ANSWER>c Receptor sites a. are a normal part of enzyme substrates. b. are protein areas on cell membranes that react with specific chemicals. c. can usually be stimulated by many different chemicals. d. are responsible for all drug effects in the body. - ANSWER>b Selective toxicity is a. the ability of a drug to seek out a specific bacterial species or microorganism. b. the ability of a drug to cause only specific adverse effects. c. the ability of a drug to cause fetal damage. d. the ability of a drug to attack only those systems found in foreign or abnormal cells. - ANSWER>d When trying to determine why the desired therapeutic effect is not being seen with an oral drug the nurse should consider a. the blood flow to muscle beds. b. food altering the makeup of gastric juices. c. the weight of the patient. d. the temperature of the peripheral environment. - ANSWER>b

Much of the biotransformation that occurs when a drug is taken occurs as part of a. the protein-binding effect of the drug. b. the functioning of the renal system. c. the first-pass effect through the liver. d. the distribution of the drug to the reactive tissues. - ANSWER>c The half-life of a drug a. is determined by a balance of all pharmacokinetic processes. b. is a constant factor for all drugs taken by a patient. c. is influenced by the fat distribution of the patient. d. can be calculated with the use of a body surface nomogram. - ANSWER>a J.B. has Parkinson's disease that has been controlled for several years with levodopa. After he begins a health food regimen with lots of vitamin B6, his tremors return, and he develops a rapid heart rate, hypertension, and anxiety. The nurse investigating the problem discovers that vitamin B6 can speed the conversion of levodopa to dopamine in the periphery, leading to these problems. The nurse would consider this problem a. a drug-laboratory test interaction. b. a drug-drug interaction. c. a cumulation effect. d. a sensitivity reaction. - ANSWER>b When reviewing a drug to be given the nurse notes that the drug is excreted in the urine. What points should be included in the nurse's assessment of the patient? a. The patient's liver function tests b. The patient's bladder tone

c. The patient's renal function tests d. The patient's fluid intake e. Other drugs being taken that could affect the kidney f. The patient's intake and output for the day - ANSWER>c, d, e When considering the pharmacokinetics of a drug, what points would the nurse need to consider? a. How the drug will be absorbed b. The way the drug affects the body c. Receptor site activation and suppression d. How the drug will be excreted e. How the drug will be metabolized f. The half-life of the drug - ANSWER>a, d, e, f Drug-drug interactions are important considerations in clinical practice. When evaluating a patient for potential drug-drug interactions, what would the nurse expect to address? a. Bizarre drug effects on the body b. The need to adjust drug dose or timing of administration c. The need for more drugs to balance the effects of the drugs being given

d. A new therapeutic effect not encountered with either drug alone e. Increased adverse effects f. The use of herbal or alternative therapies - ANSWER>b, e, f A patient reports that she has a drug allergy. In exploring the allergic reaction with the patient, which of the following might indicate an allergic response? a. Increased urination b. Dry mouth c. Rash d. Drowsiness - ANSWER>c The nurse obtains a medical history from a patient before beginning drug therapy based on an understanding of which of the following? a. Medical conditions can alter a drug's pharmacokinetics and pharmacodynamics. b. A medical history is a key component of any nursing protocol. c. A baseline of information is necessary to evaluate a drug's effects. d. The medical history is the first step in the nursing process. - ANSWER>a The nurse writes a nursing diagnosis for which reason? a. Direct medical care b. Help to increase patient compliance c. Identify actual or potential alteration in patient function d. Determine insurance reimbursement in most cases - ANSWER>c A patient receiving an antihistamine complains of dry mouth and nose. An appropriate comfort measure for this patient would be to a. suggest that the patient use a humidifier.

b. encourage voiding before taking the drug. c. have the patient avoid sun exposure. d. give the patient a back rub. - ANSWER>a When establishing the nursing interventions appropriate for a given patient a. the patient should not be actively involved. b. the patient support systems should be included only at discharge. c. teaching should be done when the patient states he or she is ready to learn. d. an evaluation of all of the data accumulated should be incorporated to achieve an effective care plan. - ANSWER>d The evaluation step of the nursing process a. is often used as a last resort. b. is important primarily in the acute setting. c. is a continuous process. d. includes making nursing diagnoses. - ANSWER>c After teaching a patient about digoxin (generic)—a drug used to increase the effectiveness of the heart's contractions—which statement indicates that the teaching was effective? a. "I need to take my pulse every morning before I take my pill." b. "If I forget my pills, I usually make up the missed dose once I remember." c. "This pill might help my hay fever when it becomes a problem." d. "I don't remember the name of it, but it is the white one." - ANSWER>a A client is being started on a laxative regimen. Before beginning the regimen the nurse performs which of the following assessments?

a. Liver function test b. Abdominal examination c. Skin color and lesion evaluation d. Lung auscultation e. 24 - hour urine analysis f. Cardiac assessment - ANSWER>a, b, c The nursing care of a patient receiving drug therapy should include measures to decrease the anticipated adverse effects of the drug. Which of the following measures would a nurse consider? a. A positive approach b. Environmental temperature control c. Safety measures d. Skin care e. Refrigeration of the drug f. Involvement of the family - ANSWER>b, c, d A nurse is preparing to administer a drug to a client for the first time. What questions should the nurse consider before actually administering the drug? a. Is this the right patient? b. Is this the right drug? c. Is there a generic drug available? d. Is this the right route for this patient? e. Is this the right dose, as ordered? f. Did I record this properly? - ANSWER>a, b, d, e, f

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply. a. A 4 - month old infant whose temperature is 38.1°C (100.5°F) b. A 3 - year old whose blood pressure is 118/80 c. A 9 - year old whose temperature is 39°C (102.2°F) d. An adolescent whose pulse rate is 70 bpm e. An adult whose respiratory rate is 20 bpm f. A 72-year old whose pulse rate is 42 bpm - ANSWER>a, d, e, f. The normal temperature range for infants is 37.1°C to 38.1°C (98.7°F-100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 bpm and the normal pulse for an older adult is 40 to 100 bpm. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8°C to 37.8°C (98.2°F-100°F; refer to Table 24 - 1, Age-Related Variations in Normal Vital Signs). A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss? a. Evaporation b. Convection c. Radiation d. Conduction - ANSWER>a. Evaporation is the conversion of a liquid to a vapor as occurs when body fluid in the form of perspiration is vaporized from the skin. With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. An example of radiation

(diffusion of heat by electromagnetic waves) is the body giving off heat from uncovered areas. In conduction, the heat is transferred to another object during direct contact, for example, body heat melting an ice pack. The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. a. A newborn who has hypothermia b. A child who has pneumonia c. An older patient who is post myocardial infarction (heart attack) d. A teenager who has leukemia e. A patient receiving erythropoietin to replace red blood cells f. An adult patient who is newly diagnosed with pancreatitis - ANSWER>a, c, d, e. The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts. While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? a. Check the pulse again in 2 hours. b. Check the blood pressure. c. Record the information. d. Report the rate to the primary care provider. - ANSWER>d. A rate of 140 beats/min

in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient. A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. a. An increase in the pulse rate b. A decrease in body temperature c. A decrease in blood pressure d. An increase in respiratory depth e. An increase in respiratory rate f. An increase in body temperature - ANSWER>a, e. The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase respiratory rate but decrease respiratory depth. Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following? a. Pulse deficit b. Pulse amplitude c. Ventricular rhythm d. Heart arrhythmia - ANSWER>a. The difference between the apical and radial pulse rate is called the pulse deficit. The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply. a. Blood pressure decreases with age.

b. Blood pressure is usually lowest on arising in the morning. c. Women usually have lower blood pressure than men until menopause. d. Blood pressure decreases after eating food. e. Blood pressure tends to be lower in the prone or supine position. f. Increased blood pressure is more prevalent in African Americans. - ANSWER>b, c, e, f. Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in African American men and women. A patient is having dyspnea. What would the nurse do first? a. Remove pillows from under the head b. Elevate the head of the bed c. Elevate the foot of the bed d. Take the blood pressure - ANSWER>b. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion. A student nurse is learning to assess blood pressure. What does the blood pressure measure?