week 9 sherpath Flashcards by Monica Galvan-Valencia

Place the steps in the order the nurse would follow when assessing a patient for infection or risk for infection.

Documentation of findings

Head-to-toe examination

Introduction of himself or herself

Collection of subjective data

Introduction of himself or herself

Collection of subjective data

Head-to-toe examination

Documentation of findings

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Which question by the nurse specifically assesses the patient for infection or risk for infection?

“When was the last time you took an antibiotic?”

“Have you had a change in activity lately?”

Do you experience urinary pain or frequency?”

“Are you able to finish all of your daily meals?”

Do you experience urinary pain or frequency?”

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Match the diagnostic test with the information that it provides.

Provides counts for RBCs, WBCs, platelets, and reticulocytes

Detects causative organism and determines effective antibiotic treatment

Provides the number of each type of WBC

Provides the overall number of all WBCs

Answer choices

White blood cell (WBC) count

Complete blood count (CBC)

Culture and sensitivity (c and S)

White blood cell (WBC) differential

Provides counts for RBCs, WBCs, platelets, and reticulocytes
Complete blood count (CBC)

Detects causative organism and determines effective antibiotic treatment
Culture and sensitivity (c and S)

Provides the number of each type of WBC
White blood cell (WBC) differential

Provides the overall number of all WBCs
White blood cell (WBC) count

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Order white blood cells from most prevalent to least prevalent in the absence of infection.

Basophils

Neutrophils

Monocytes

Eosinophils

Lymphocytes

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Basophils

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Which white blood cells are responsible for the signs and symptoms of inflammation?

Neutrophils

Monocytes

Eosinophils

Basophils

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Match the type of inflammation with its description.

Limited to the area of site of injury

Involves multiple organs or tissues

Quickly severe, lasting only a few days

Prolonged response lasting months to years

Answer choices

Systemic inflammation

Localized inflammation

Chronic inflammation

Acute inflammation

Limited to the area of site of injury
Localized inflammation

Involves multiple organs or tissues
Systemic inflammation

Quickly severe, lasting only a few days
Acute inflammation

Prolonged response lasting months to years
Chronic inflammation

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Which factors increase the older adult’s susceptibility to infections?

Select all that apply.

Decreased immune responses

Increased cortisol production

Decreased cough reflex

Incomplete bladder emptying

Reduced vascular supply

Excessive epidermal thickening

Decreased immune responses

Decreased cough reflex

Incomplete bladder emptying

Reduced vascular supply

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Which potential infections would a nurse focus on when teaching preventive precautions to an immobile patient being discharged to home?

Select all that apply.

Skin infections

Cardiovascular infections

Urinary tract infections (UTIs)

Respiratory infections

Musculoskeletal infections

Skin infections

Urinary tract infections (UTIs)

Respiratory infections

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Match the category of infection with its characteristics and example.

Develops rapidly (e.g., common cold)

Lasts months (e.g., mononucleosis)

Pain (e.g., pressure injury)

High fever (e.g., sepsis)

Answer choices

Acute infection

Chronic infection

Systemic infection

Localized infection

Develops rapidly (e.g., common cold)
Acute infection

Lasts months (e.g., mononucleosis)
Chronic infection

Pain (e.g., pressure injury)
Localized infection

High fever (e.g., sepsis)
Systemic infection

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Which patient finding is indicative of a localized infection?

Tachycardia

Fatigue

Abscess

Chills

Abscess

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Which techniques can the nurse use for collecting patient assessment data?

Select all that apply.

Performing a general assessment

Speaking with the patient’s family

Consulting the patient’s medical file

Performing the physical assessment

Obtaining a thorough history

Speaking with the patient’s roommate

Performing a general assessment

Speaking with the patient’s family

Consulting the patient’s medical file

Performing the physical assessment

Obtaining a thorough history

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Which data collected during the nurse-patient interview is a subjective finding?

Bowel sounds active

Fatigue

Swollen left elbow

Blood pressure of 150/72 mm Hg

Fatigue

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Which objective patient findings alert the nurse to the presence of infection or the risk for infection?

Select all that apply.

Pressure injuries

Enlarged lymph nodes

Hyperactive bowel sounds

Reports of pain

Decreased breath sounds

Pressure injuries

Enlarged lymph nodes

Hyperactive bowel sounds

Decreased breath sounds

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Which blood test specifically assesses for the presence of an active inflammatory response?

White blood cell (WBC) count

Complete blood count (CBC)

Culture and sensitivity (C&S) test

Erythrocyte sedimentation rate (ESR)

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Which laboratory finding is abnormal and must be reported to the health care provider?

White blood cell (WBC) count of 10,100 cells/mm3

Erythrocyte sedimentation rate (ESR) 20 mm/hr

Serum complement 140 hemolytic units

C-reactive protein of 0.9 mg/L

Serum complement 140 hemolytic units

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Which symptoms are consistent with a chronic inflammatory disorder?

Redness, swelling, and pain to the ankle while playing basketball

Pain and fever from a streptococcal sore throat

Pain and swelling of the knees from arthritis

Discomfort from a strained back muscle

Pain and swelling of the knees from arthritis

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Which symptoms are consistent with a chronic inflammatory disorder?

Redness, swelling, and pain to the ankle while playing basketball

Pain and fever from a streptococcal sore throat

Pain and swelling of the knees from arthritis

Discomfort from a strained back muscle

Pain and swelling of the knees from arthritis

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Which patient has the most risk factors for developing an infection?

46-year-old recovering from elective noninvasive surgery

30-year-old with newly diagnosed early eating disorder

70-year-old with diabetes and an indwelling urinary catheter

50-year-old smoker who is receiving an intravenous antibiotic

70-year-old with diabetes and an indwelling urinary catheter

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Which finding would lead the nurse to conclude that a patient’s surgical incision that was inflamed is now infected?

Greenish drainage

Warm to the touch

Swelling at the edges

Slightly red color

Greenish drainage

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Which manifestations indicate systemic infection and warrant further patient assessment?

Select all that apply.

Blood pressure of 164/104 mm Hg

Temperature 101.3°F (38.5°C) orally

Heart rate 122 beats/min

Respiratory rate 16 breaths/min

Skin warm to touch and moist

Temperature 101.3°F (38.5°C) orally

Heart rate 122 beats/min

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Which phrase describes medical asepsis?

Absence of all infectious agents

Procedure known as clean technique

Requires use of sterile gloves

Prevents microbial entry into body

Procedure known as clean technique

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Which statement is correct regarding hand hygiene in the health care setting?

Soap and water effectively reduce microorganisms on visibly dirty hands.

Infectious agents are killed by soap and water when washing hands.

Washing hands with very hot water helps eliminate a greater number of bacteria.

Non–alcohol-based hand sanitizers inhibit microorganism growth on hands.

Soap and water effectively reduce microorganisms on visibly dirty hands.

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An effective alcohol-based hand scrub must contain at least __ percent alcohol.

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Match the situation to the type of personal protective equipment required.

Head cover

Goggles

Gloves

Gown

Answer choices

Surgery or labor and delivery

Protection from airborne microbes

Patient on transmission precautions

Sprays from respiratory droplets

Direct contact with body fluids

Head cover
Surgery or labor and delivery

Goggles
Sprays from respiratory droplets

Gloves
Direct contact with body fluids

Gown
Patient on transmission precautions

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Place the personal protective equipment (PPE) in the order in which the nurse would remove them. Shoe covers Gown Eyewear Gloves Mask

Gloves Eyewear Gown Mask Shoe covers

Which practices would be included by the nurse when teaching about standard precautions? Select all that apply. Hand hygiene Cough etiquette Patient cleanliness Safe injection practices Use of personal protective equipment (PPE)

Hand hygiene Cough etiquette Safe injection practices Use of personal protective equipment (PPE)

Which precaution would the nurse take when handling needles (sharps) to prevent an accidental needlestick? Recapping the needle after use Using a needleless system whenever possible Placing covered intravenous (IV) cannulas securely in the trash Flushing needles with water before disposing of them

Using a needleless system whenever possible

As a member of the infection control committee, which action would the nurse suggest to help control transmission of respiratory infections among staff during influenza season? Role model wearing gloves during patient care. Speak to peers about obtaining their immunizations. Teach hand hygiene to unlicensed assistive personnel. Post signs in bathrooms demonstrating cough etiquette.

Post signs in bathrooms demonstrating cough etiquette.

Which transmission-based precaution would the nurse take for a seriously ill patient being admitted for influenza? Avoid admitting through the reception area. Admit to an airborne infection isolation room. Obtain an N95 disposable respirator mask. Provide a mask for the patient if leaving the room.

Provide a mask for the patient if leaving the room.

Which activities can a nurse easily participate in if interested in slowing infection transmission within the community? Select all that apply. Closing schools during influenza pandemics Changing employer policies regarding sick leave Participating in local handwashing campaigns Working locally to encourage immunizations Avoiding mass gatherings during flu season

Participating in local handwashing campaigns Working locally to encourage immunizations

Which source is best for the nurse to recommend for patients interested in information about the updated immunization schedule for adults? Their health care provider’s clinic or office The Centers for Disease Control and Prevention (CDC) immunization website Any health care provider at a local pharmacy The US government website

The Centers for Disease Control and Prevention (CDC) immunization website

Which home care intervention helps reduce the transmission of infections? Reporting infections as early as recognized Using disposable dishes and utensils Soaking clothing in bleach solution Isolating the infected individual from others

Reporting infections as early as recognized

Which diseases can the federal government order patients to be isolated and/or quarantined for? Select all that apply. Smallpox Human immunodeficiency virus (HIV)/Acquired - - immunodeficiency syndrome (AIDS) Measles Cholera Yellow fever Diphtheria

Smallpox Cholera Yellow fever Diphtheria

Place in order the steps of establishing a sterile field. Open sterile packages away from the body. Do not turn away from the sterile field. Don a facemask if required. Perform thorough hand hygiene. Establish the sterile field above waist level.

Don a facemask if required. Perform thorough hand hygiene. Establish the sterile field above waist level. Open sterile packages away from the body. Do not turn away from the sterile field.

Match the cleaning method with its use. Germicide Chemical sterilization Physical sterilization Disinfection Answer choices Cleans medical equipment and skin Uses chlorhexidine Process that uses steam or radiation Process that uses gases

Germicide Uses chlorhexidine Chemical sterilization Process that uses gases Physical sterilization Process that uses steam or radiation Disinfection Cleans medical equipment and skin

Which personal protective equipment (PPE) would the nurse don before observing a sterile procedure in the operating room? Mask Gown Hair cover Sterile gloves

Mask

Which actions would a nurse take when caring for a patient with cellulitis? Select all that apply. Implement wound care Obtain a wound culture Implement isolation precautions Review the complete blood count Administer antibiotics

Implement wound care Obtain a wound culture Review the complete blood count Administer antibiotics

Which intervention would a nurse anticipate specifically for a patient suspected of meningitis? Antibiotics Lumbar puncture Inputs and outputs Complete blood count

Lumbar puncture

Which term describes the administration of a medication by a nurse? Dependent intervention Independent intervention Interdependent intervention Nurse-initiated intervention

Dependent intervention

Which phrases describe the purpose of hand hygiene? Select all that apply. Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission Enhances the patient relationship Kills microorganisms

Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission

Which step is first in the sequence for donning personal protective equipment (PPE)? Hand hygiene Head cover Mask Gown

Hand hygiene

Which infection would require a nurse to don a fitted N95 respiratory mask? Tuberculosis Influenza Pneumonia Methicillin-resistant Staphylococcus aureus (MRSA)

Tuberculosis

Which statements best describe the purpose for greeting the patient and explaining the need for personal protective equipment (PPE)? Select all that apply. Eases fear and misunderstanding Creates a professional relationship Builds a trusting relationship Fulfills legal requirements Eliminates later confusion

Eases fear and misunderstanding Creates a professional relationship Builds a trusting relationship

Which piece of personal protective equipment (PPE) would the nurse consistently don when anticipating that contact with a patient’s body secretions will be possible? Gloves Masks Eyewear Gown

Gloves

In which situation is it permissible for the nurse to use an alcohol-based hand sanitizer? Before eating lunch or ingesting food When hands are not visibly soiled After use of the bathroom by the nurse After known exposure to norovirus

When hands are not visibly soiled

Which behavior indicates the need for additional teaching after educating a patient about respiratory etiquette? Using sanitizer hand wipes after sneezing Dropping used tissues into a waste receptacle Reusing tissues for a productive cough Wearing a mask when leaving the room

Reusing tissues for a productive cough

Which nursing student’s note would the nurse correct? Standard precautions used during bed, bath, and mouth care. Education provided to patient about cough etiquette. Location of site where injection was administered. Patient performed a return demonstration on wound care using gloves.

Standard precautions used during bed, bath, and mouth care.

Which infection would prompt the nurse to implement contact precautions? Hepatitis A Streptococcal pneumonia Influenza Chickenpox

Hepatitis A

By which means are pathogens transmitted through droplets, requiring infected patients to be placed on protective precautions? Select all that apply. Coughing Sneezing Suctioning Eating Talking

Coughing Sneezing Suctioning Talking

Which infection would require a patient to be admitted to the airborne infection isolation room? Pharyngeal diphtheria Meningococcal sepsis Staphylococcus aureus Varicella zoster

Varicella zoster

Match the transmission-based precaution with the mode of transmission it prevents. Person to person Coughing, sneezing Suspended particles Answer choices Droplet Airborne Contact

Person to person contact Coughing, sneezing droplet Suspended particles airborne

Match the type of transmission-based precaution with the infection for which it is implemented. Herpes simplex virus (HSV) Rubella Rubeola Answer choices Airborne Contact Droplet

Herpes simplex virus (HSV) Contact Rubella Droplet Rubeola airborne

Which type of action is the nurse taking to reduce the spread of infections by not going to work when sick? Personal Community Home Employee

Personal

Which action can communities engage in to help reduce infections among their citizens? Encouraging and facilitating immunization programs Providing containers for used needle disposal to patients Assisting with health care environment modifications Educating patients about home infection control measures

Encouraging and facilitating immunization programs

Which group(s) does the Centers for Disease Control and Prevention (CDC) apply the term quarantine to? Select all that apply. People Animals Cargo Buildings Institutions

People Animals Cargo Buildings

Match the precaution with its corresponding description. Separates sick and contagious people from others Separates people exposed to a contagious disease Separates people with weak immune systems Answer choices Isolation Protective isolation Quarantine

Separates sick and contagious people from others isolation Separates people exposed to a contagious disease Quarantine Separates people with weak immune systems Protective isolation

Which medical asepsis interventions by the nurse directly protect the patient from infection? Select all that apply. Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Placing items wet from body fluids in biohazard bags Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports Removing excess linens from the patient’s room

Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports

Which actions are required by the nurse when preparing for a sterile procedure? Select all that apply. Keeping sterile surfaces dry Setting up the sterile field Leaving the room for supplies Checking packaging integrity Monitoring activities of others Delegating preparations to unlicensed assistive personnel (UAP)

Keeping sterile surfaces dry Setting up the sterile field Checking packaging integrity Monitoring activities of others

Which action would the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? Health care provider touched sterile field one-half inch from edge Health care provider reached over sterile field to pick up a towel Masked assistant talked over the sterile field Sterile packages opened facing away from body

Health care provider reached over sterile field to pick up a towel

Which procedure is necessary for equipment being used to enter a sterile body cavity? Sanitization Disinfection Sterilization Decontamination

Sterilization

Which type of infection would a nurse suspect when caring for a patient who has a prescription for a Clostridium difficile test? Respiratory tract infection Urinary tract infection Gastrointestinal infection Cellulitis

Gastrointestinal infection

A nurse caring for a patient with an infection would anticipate a temperature less than_ _ °F when the infection has resolved.

100.4

Which actions by the nurse would be considered independent nursing interventions? Select all that apply. Counseling a patient Administration of antibiotics Repositioning a patient to enhance comfort Participating in a patient care conference Teaching a postoperative patient how to prevent surgical site infection

Counseling a patient Repositioning a patient to enhance comfort Teaching a postoperative patient how to prevent surgical site infection

Which part of the brain maintains a consistent internal body temperature despite environmental extremes? Thalamus Brainstem Cerebellum Hypothalamus

Hypothalamus

Which internal process provides the primary source of heat production? Exercise Hormones Metabolism Convection

Metabolism

Which mechanisms primarily enhance heat loss from the body? Select all that apply. Radiation Digestion Conduction Convection Evaporation

Radiation Conduction Convection Evaporation

Infants under the age of ___ months have immature regulatory thermoregulation systems. Record answer as a whole number.

Which factors affect body temperature? Select all that apply. Stress Height Smoking Hormones Environment Circadian rhythms

Stress Smoking Hormones Environment Circadian rhythms

Which assessment question would the nurse ask a patient prior to measuring temperature? “Do you have a family history of fevers?” “Have you exercised in the last 30 minutes?” “How would you describe your body temperature?” “At which site would you like me to take your temperature?”

“Have you exercised in the last 30 minutes?”

Match the characteristic with the correct temperature assessment site. Most common site for measuring temperature Measures core or deep tissue temperature Tolerated by infants and young children Very accurate reading but not preferred by patient Answer choices Rectal Tympanic Temporal Oral

Most common site for measuring temperature Oral Measures core or deep tissue temperature Tympanic Tolerated by infants and young children Temporal Very accurate reading but not preferred by patient Rectal

Which temperature range is expected for an adult patient? 99.4° to 99.7°F (37.4° to 37.6°C) 98° to 98.6°F (36.6° to 37°C) 93.2° to 96.8°F (34° to 36°C) 95.9° to 99.5°F (35.5° to 37.5°C)

95.9° to 99.5°F (35.5° to 37.5°C)

Which areas of the human body are most vulnerable to frostbite? Select all that apply. Toes Wrists Earlobes Abdomen Tip of nose

Toes Earlobes Tip of nose

Which cues would the nurse likely observe in a patient who has hyperthermia? Select all that apply. Dizziness Hot skin Cool, white skin Rapid heart rate Increased urinary output

Dizziness Hot skin Rapid heart rate

Which cues related to thermoregulation can be found in the medical record? Select all that apply. Results of white blood cell count Presence of growth on a culture Patient interview Temperature readings on graphics Levels of hormones

Results of white blood cell count Presence of growth on a culture Temperature readings on graphics Levels of hormones

Which cues would prompt the nurse to select Fever as a hypothesis? Select all that apply. 93°F (33.9°C) Presence of infection Chills Anorexia Dehydration Cool skin

Presence of infection Chills Anorexia Dehydration

Which patient would the nurse assess first? One with heatstroke One who has controlled diabetes One with anorexia One who has an infection

One with heatstroke

Which action would the nurse take after developing outcomes for a patient with a fever? Determine goals with the patient. Implement care. Select solutions. Check the chart for laboratory results.

Select solutions.

Which items would the nurse offer to a patient with a low body temperature? Select all that apply. Hot soup Head coverings Regular hot tea or coffee Warmed blankets Warmed intravenous fluids

Hot soup Head coverings Warmed blankets Warmed intravenous fluids

Match the intervention with its mechanism of action. Reduce metabolic demands and oxygen use Identify the most effective antibiotics Help meet the increased metabolic demands produced by fever Replace losses from increased respirations and diaphoresis Answer choices Oxygen and nutrients Laboratory tests Oral and IV fluids Sleep and rest

Reduce metabolic demands and oxygen use Sleep and rest Identify the most effective antibiotics Laboratory tests Help meet the increased metabolic demands produced by fever Oxygen and nutrients Replace losses from increased respirations and diaphoresis Oral and IV fluid

Which nonpharmacologic interventions lower a patient’s fever? Select all that apply. Ice packs Acetaminophen Cooling pads Cool sponge baths Warmed blankets

Ice packs Cooling pads Cool sponge baths

Which mechanism of action would lower a patient’s temperature when taking antipyretics? Increase prostaglandin production Lower the hypothalamus set-point Reduce heat-loss processes Transfer of heat as waves or particles of energy

Lower the hypothalamus set-point

Which statement from the nurse indicates a correct interpretation of a higher temperature at 1830 when compared to the temperature at 1600? “It is normal for temperatures to fluctuate from one hour to the next.” “I should start taking the temperature every 30 minutes.” “This is a typical response based on circadian rhythms.” “This should be reported immediately to the health care provider.”

“This is a typical response based on circadian rhythms.”

Match the mechanism of heat loss to its intervention. Cooling a patient with a fan Positioning a patient close to a cold window Placing a cool rag on the patient’s forehead Checking the patient with a fever for diaphoresis Answer choices Evaporation Radiation Conduction Convection

Cooling a patient with a fan Convection Positioning a patient close to a cold window Radiation Placing a cool rag on the patient’s forehead Conduction Checking the patient with a fever for diaphoresis Evaporation

Which patient would the nurse monitor closely for alterations in temperature control? One who requires assistance with activities of daily living One who just received a series of x-rays for a broken leg during a sports game One who is undergoing a routine wellness examination prior to an international flight One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)

One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke)

Which cues would the nurse likely observe in a patient who has a temperature of 92°F (33.3°C)? Select all that apply. Drowsiness Muscle cramps Excessive thirst Pale, cool skin Decreased urinary output

Drowsiness Pale, cool skin Decreased urinary output

Which statements from the nurse indicate a correct understanding of assessment sites for temperature? Select all that apply. “Rectal temperature readings are avoided for infants.” “I can get an accurate tympanic temperature reading on an unconscious patient.” “A patient who uses an oxygen mask may have an inaccurate temperature measurement - if taken by mouth.” “I can get an accurate temperature reading by placing the thermometer to the right of the patient’s axilla.” “I can use temperature-sensitive strips on the forehead for the patient who is diaphoretic.”

“Rectal temperature readings are avoided for infants.” “I can get an accurate tympanic temperature reading on an unconscious patient.” “A patient who uses an oxygen mask may have an inaccurate temperature measurement - if taken by mouth.”

Which action would the nurse take immediately after assessing a patient’s temperature to determine whether the patient has heat exhaustion or heatstroke? Touch the patient’s skin. Retake the patient’s temperature. Start the prescribed antibiotic. Obtain a culture and sensitivity test.

Touch the patient’s skin.

Place the steps in order when caring for a patient who is febrile. Develop expected outcomes. Select solutions for Fever. Gather cues from the temperature assessment. Reassess temperature to evaluate care for Fever. Administer antipyretic. Analyze cues to determine hypothesis of Fever.

Gather cues from the temperature assessment. Analyze cues to determine hypothesis of Fever. Develop expected outcomes. Select solutions for Fever. Administer antipyretic. Reassess temperature to evaluate care for Fever.

Which interventions would the nurse select for a patient with hypothermia who was rescued from drowning in a freezing river? Select all that apply. Administer prescribed warmed intravenous fluids. Apply several layers of warmed blankets. Keep the patient’s wet clothing on to avoid heat loss. Wrap warm, dry towels around the patient’s head. Apply a cooling blanket to keep the body accustomed to the cold.

Administer prescribed warmed intravenous fluids. Apply several layers of warmed blankets. Wrap warm, dry towels around the patient’s head.

Which action by the nurse supports the hypothesis of Hypothermia when the patient presents with decreased respirations, cool skin, and low body temperature? Ask the patient about feeling feverish. Request laboratory work to check the patient’s iron levels. Check the patient’s urinary output, which is increased. Take the patient’s blood pressure, which shows hypotension.

Take the patient’s blood pressure, which shows hypotension.

Which statement from the nurse indicates appropriate clinical judgment in choosing a temperature assessment site? “Because the patient has a low white blood cell count, I will not take a rectal temperature.” “The unconscious patient will benefit the most from temperature readings taken via the oral route.” “The older adult patient has been sipping on cool water because of dehydration, but an accurate oral temperature reading is still possible.” “Because the pediatric patient is slightly perspiring, temperature measurement by the temporal artery on the forehead will be avoided.”

“Because the patient has a low white blood cell count, I will not take a rectal temperature.”

Which actions would the nurse take for a patient who has a fever? Select all that apply. Lower the room temperature. Decrease stress level. Encourage ambulation. Monitor red blood cell count. Review culture and sensitivity reports.

Lower the room temperature. Decrease stress level. Review culture and sensitivity reports.

Which patient temperature measurements would cause the nurse to intervene? Select all that apply. Newborn: 96°F (35.5°C) 6-year-old: 98.6°F (37°C) 15-year-old: 100°F (37.8°C) Adult: 97.9°F (36.6°C) Older adult: 93°F (33.9°C)

15-year-old: 100°F (37.8°C) Older adult: 93°F (33.9°C)

Which instruction will the nurse give the parent who asks how much aspirin should be given to a 3-year-old with a viral infection? “Follow the dosing on the label.” Let the parent know the standard dose. “Do not give the medication.” “Use the dosage cup with the medication.”

“Do not give the medication.”

Which outcome would the nurse develop for a patient who is afebrile? Patient’s temperature will return to expected range within 1 hour of treatment. Patient’s temperature will be within the expected range until discharge. Patient’s temperature will increase by 1° until within the expected range. Patient’s temperature will decrease by 1° until within the expected range.

Patient’s temperature will be within the expected range until discharge.

Match each condition with its proper definition. Exposure to extreme cold, resulting in low body temperature Ice crystals form inside cells, causing tissue damage Rise in body temperature above expected, caused by trauma or illness High body temperature, caused by prolonged exposure to extreme heat Answer choices Hypothermia Fever Hyperthermia Frostbite

Exposure to extreme cold, resulting in low body temperature Hypothermia Ice crystals form inside cells, causing tissue damage Frostbite Rise in body temperature above expected, caused by trauma or illness Fever High body temperature, caused by prolonged exposure to extreme heat Hyperthermia

Which cues alert the nurse a patient with hypothermia is improving? Select all that apply. Temperature decreases. Temperature increases. Urinary output increases. Blood pressure decreases. Culture growth decreases.

Temperature increases. Urinary output increases.

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Young adult with a fever Older adult patient with a fever Middle-aged adult with heatstroke Teenager who is afebrile

Middle-aged adult with heatstroke Older adult patient with a fever Young adult with a fever Teenager who is afebrile

Which cues alert the nurse that a patient with hyperthermia is declining? Select all that apply. Temperature increases. Temperature decreases. White blood cells decrease. Heart rate increases. Dizziness increases..

Temperature increases. Heart rate increases. Dizziness increases..

Which action would the nurse take when measuring the tympanic temperature of a 5-year-old? Pull the ear down and back. Pull the pinna up and back. Angle the probe toward the umbilicus. Angle the probe toward the forehead.

Pull the pinna up and back.

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports an adult patient has a 99.5°F (37.5°C) temperature? Recognize this is an expected finding. Immediately notify the health care provider. Tell the UAP to start taking the temperature every 1 hour. Inform the family that the patient may be transferred.

Recognize this is an expected finding.

Which instruction would the nurse share with a male patient who calls the clinic and tells the nurse that over a 24-hour period he has taken two extra strength acetaminophen tablets (1000 mg) every 4 hours for a fever? Acetaminophen is a drug that will reduce your fever. Continue to take the drug. This is too much acetaminophen. You have probably damaged your liver.

This is too much acetaminophen.

When the nurse is reviewing medications, for which patients would the nurse need to notify the health care provider? Select all that apply. Patient with liver disease who is receiving acetaminophen Patient with a fever who is receiving ibuprofen Patient with an acetaminophen prescription for 3 grams/day Patient who is taking an anticoagulant and aspirin for fever Patient who has a bleeding disorder taking ibuprofen

Patient with liver disease who is receiving acetaminophen Patient who is taking an anticoagulant and aspirin for fever Patient who has a bleeding disorder taking ibuprofen

Match the intervention to its pathophysiologic cause. Heat-loss processes outpace heat-generating processes Heat-generating processes overcome heat-loss processes Heat-loss processes equal heat-generating processes Hypothalamus set-point is elevated Answer choices Administer antipyretics Institute cooling measures Institute rewarming measures Use measures to maintain expected temperature

Heat-loss processes outpace heat-generating processes Institute rewarming measures Heat-generating processes overcome heat-loss processes Institute cooling measures Heat-loss processes equal heat-generating processes Use measures to maintain expected temperature Hypothalamus set-point is elevated Administer antipyretics

Which site is the natural pacemaker of the heart? Sinoatrial node Atrioventricular node Purkinje fibers Internodal pathway

Sinoatrial node

Which explanation would the nurse make when discussing a patient’s cardiac output? The number of heartbeats in 1 minute The amount of blood the heart pumps per minute The amount of time it takes for one cardiac cycle The number of pulse sites that are palpable

The amount of blood the heart pumps per minute

Which pulse site would the nurse use that is the most definitive site to determine a patient’s cardiac health? Apical Radial Peripheral Carotid

Apical

Which factors can affect a patient’s heartbeat? Select all that apply. Fever Hunger Exercise Medications Hypovolemia

Fever Exercise Medications Hypovolemia

Which questions would the nurse ask a patient before performing a pulse assessment? Select all that apply. Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath? Have you engaged in any type of exercise in the past 90 minutes?

Do you smoke? What medications do you take? Are your hands or feet swollen? Do you experience shortness of breath?

In which instances would the nurse listen to an apical pulse? Select all that apply. If the patient has a palpable peripheral pulse If the patient has weak heart contractions When the patient’s pedal pulse is difficult to palpate When the patient’s radial pulse is 86 and irregular When a medication may alter the patient’s cardiac function

If the patient has weak heart contractions When the patient’s radial pulse is 86 and irregular When a medication may alter the patient’s cardiac function

Match the pulse site with its location. Either side of the neck Either side of the forehead Inner aspect of the arm Inside the wrist Answer choices Brachial Radial Pedal Temporal Apical Carotid

Either side of the neck Carotid Either side of the forehead Temporal Inner aspect of the arm Brachial Inside the wrist Radial

Match the expected pulse parameters with the appropriate age group. Newborn (awake or asleep) 6-year-old 15-year-old Adult Answer choices 80–180 75–110 50–90 60–100

Newborn (awake or asleep) 80–180 6-year-old 75–110 15-year-old 50–90 Adult 60–100

Which conditions would be likely to cause tachycardia? Select all that apply. Beta blocker medication Sleep Anemia Bronchodilator medication Drop in blood pressure Athletic fitness level

Anemia Bronchodilator medication Drop in blood pressure

Which actions would the nurse perform to obtain patient observation cues for pulse? Select all that apply. Interview the patient Check laboratory results for the patient’s calcium level Visually inspect the patient for alterations Review the patient’s baseline on the graphic/flow sheet Read the nurse’s notes about the patient’s pulse

Interview the patient Visually inspect the patient for alterations

Which hypothesis would the nurse develop for an adult patient who has a pulse rate of 40 and is sluggish and confused? Tachycardia Bradycardia Risk for Bradycardia Heart Rate Within Normal Limits

Bradycardia

Which adult patient would the nurse assess first? One with heart disease One with tachycardia One with stable breathing One with patent (open) airway

One with tachycardia

Which solution would the nurse consider for a patient with bradycardia? Suggest activities to increase the heart rate. Administer medications to slow the heart rate. Encourage measures to stabilize heart rhythm. Document patient’s pulse rate alteration will resolve.

Suggest activities to increase the heart rate.

Which actions would a nurse take for a patient who has tachycardia from low fluid volume? Select all that apply. Administer prescribed fluid replacement. Administer diuretic medication. Administer prescribed oxygen. Prepare patient for an emergency pacemaker insertion. Prepare patient for an electrocardiogram.

Administer prescribed fluid replacement. Administer prescribed oxygen. Prepare patient for an electrocardiogram.

Which treatment option would the nurse anticipate for a patient with bradycardia whose pulse continues to decrease? Discontinue continuous monitoring. Prepare patient for an emergency pacemaker. Transfer patient to a long-term care facility. Consult a physical therapist.

Prepare patient for an emergency pacemaker.

Teach patient to move extremities periodically Encourage oral intake Assess heart sounds Balance periods of rest and exercise Answer choices Tissue perfusion Fluid volume Activity Cardiac output

Teach patient to move extremities periodically Tissue perfusion Encourage oral intake Fluid volume Assess heart sounds Cardiac output Balance periods of rest and exercise Activity

List the electrical impulse for the conduction cycle in the heart, beginning with the natural pacemaker. Right and left bundle branches Bundle of His Internodal pathway Atrioventricular node Purkinje fibers Sinoatrial node

Sinoatrial node Internodal pathway Atrioventricular node Bundle of His Right and left bundle branches Purkinje fibers

Match the numeric value the nurse would document for each pulse description. Normal pulse, able to palpate with normal pressure Bounding pulse, may be able to see pulsation Weak and thready, difficult to palpate Absent pulse Answer choices 1+ 3+ 2+ 0

Normal pulse, able to palpate with normal pressure 2+ Bounding pulse, may be able to see pulsation 3+ Weak and thready, difficult to palpate 1+ Absent pulse 0

Which factors would the nurse consider when the patient’s pulse rate is decreased? Select all that apply. Age Stress Hypoxia Hypovolemia Hypothyroidism

Age Hypothyroidism

At which site would the nurse assess the patient’s apical pulse? Thumb side of the wrist Left fifth and sixth intercostal space Right midclavicular line Simultaneously on both sides of the neck

Left fifth and sixth intercostal space

Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? Select all that apply. Raise the head of the bed. Slowly ambulate the patient. Offer noncaffeinated beverages. Administer fluid replacement. Monitor potassium and calcium levels.

Offer noncaffeinated beverages. Administer fluid replacement. Monitor potassium and calcium levels.

Which action would the nurse take after obtaining a patient’s regular radial pulse rate of 45 in 30 seconds? Document the appropriate heart rate. Take the radial pulse for 1 full minute. Find the point of maximal impulse. Notify the health care provider immediately.

Document the appropriate heart rate.

Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure? Select all that apply. Pain Older age Fever Exercise A drop in blood pressure

pain fever A drop in blood pressure

Match the pulse site to when each site is assessed by the nurse. To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest To measure blood pressure To determine discrepancies with radial pulse To assess circulation to the foot Answer choices Dorsalis pedis Brachial Apical Carotid

To check pulse during cardiopulmonary resuscitation (CPR) or cardiac arrest Carotid To measure blood pressure Brachial To determine discrepancies with radial pulse Apical To assess circulation to the foot Dorsalis pedis

Which action would the nurse take to obtain a patient’s apical pulse? Place a cooled stethoscope on the chest. Turn the patient to the right side. Listen at the angle of Louis. Count “lub-dub” as one beat.

Count “lub-dub” as one beat.

Which patient pulse rates would the nurse report as unexpected (abnormal)? Select all that apply. 150 for a newborn 52 for an older adult 90 for a 6-year-old 110 for a 15-year-old 180 for a 1-year-old

52 for an older adult 110 for a 15-year-old 180 for a 1-year-old

Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate? Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. Patient will maintain capillary refill to fingers/toes, skin color, skin integrity, and skin temperature of extremities at the 2-week follow-up appointment. Patient will maintain adequate fluid volume within 8 hours. Patient will exhibit good tissue perfusion.

Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions.

Which pulse site would the nurse check when an infant appears lifeless? Carotid Femoral Brachial Popliteal

Brachial

In which patient instances would the nurse use a Doppler unit to assess pulse? Select all that apply. 34-year-old patient with an irregular heart rhythm 56-year-old morbidly obese patient with hardening of the arteries 45-year-old patient with intestinal problems 62-year-old patient with obstructed blood vessels in the feet 26-year-old patient with poor circulation in the lower extremities

56-year-old morbidly obese patient with hardening of the arteries 62-year-old patient with obstructed blood vessels in the feet 26-year-old patient with poor circulation in the lower extremities

Which actions would the nurse take when the nurse finds the following pulse rates on the flow sheet: 86, 94, 100, 105, 110? Select all that apply. Reassess cardiac system. Perform a head-to-toe assessment. Review medications. Notify the health care provider. Monitor heart rate every 4 hours. Review electrolyte levels.

Reassess cardiac system. Perform a head-to-toe assessment. Review medications. Notify the health care provider. Review electrolyte levels.

What heart rate would the nurse record for a patient’s heart rate of 46 beats in 30 seconds? ____ Beats/min

Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells? This test will monitor your heart rate and rhythm just during sleep. This test utilizes a portable device attached to the chest by electrodes. It is an implantable device that is surgically inserted under the skin to continuously monitor the heart’s activity. It is a device intended to convert life-threatening arrhythmias of the heart to normal sinus rhythm.

This test utilizes a portable device attached to the chest by electrodes.

Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? Select all that apply. Hypothermia Beta blocker administration Increased intracranial pressure Hyperthyroidism Overexertion

Hypothermia Beta blocker administration Increased intracranial pressure

Which cues would the nurse assess for in an adult patient with bradycardia? Select all that apply. Pulse rate 125 Sluggish Lethargic Confused Bronchodilator prescription

Sluggish Lethargic Confused

Which finding would the nurse observe in an adult patient with Bradycardia who is improving? Pulse rate increases to 110. Pulse rate decreases from 60 to 50. Reflexes increase. Responses decrease.

Reflexes increase.

Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? Select all that apply. Encourage oral fluid intake. Elevate legs when at rest. Check peripheral pulses. Balance periods of rest and exercise. Assess heart sounds.

Elevate legs when at rest. Check peripheral pulses. Balance periods of rest and exercise. Assess heart sounds.

Match the pulse site the nurse would use to assess each pulse. Medial surface of both ankles Behind both knees On top of both feet By the groin on both sides Answer choice Popliteal Posterior tibial Apical Pedal Femoral Temporal

Medial surface of both ankles Posterior tibial Behind both knees Popliteal On top of both feet Pedal By the groin on both sides Femoral

Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase? Select all that apply. Notify health care provider. Assist with electrical cardioversion. Transfer to intensive care unit. Prepare to insert an emergency pacemaker. Suggest a consult with a cardiologist. Initiate cardiopulmonary resuscitation (CPR).

Notify health care provider. Assist with electrical cardioversion. Transfer to intensive care unit. Suggest a consult with a cardiologist.

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Older adult patient with chronic heart disease Adult patient with heart rate of 180 Older adult patient with no respirations Middle-aged patient with a heart rate of 65

Older adult patient with no respirations Adult patient with heart rate of 180 Older adult patient with chronic heart disease Middle-aged patient with a heart rate of 65

Which definition of breathing is accurate? The exchange of oxygen between alveoli and red blood cells The movement of red blood cells carrying oxygen to tissues and cells The movement of oxygen in and out of the lungs, or inhaling and exhaling The active, conscious effort of moving the lungs and chest wall

The movement of oxygen in and out of the lungs, or inhaling and exhaling

Match the stimulus or action to its corresponding physiologic receptor site. Chemoreceptors in aortic arch, carotid arteries Receptors in medulla Receptors in lungs and muscles Chemoreceptors located throughout the body Answer choices React to high levels of carbon dioxide Stimulate respiratory centers in medulla and pons Provide stretch input to medulla and pons React to hypoxemia

Chemoreceptors in aortic arch, carotid arteries React to hypoxemia Receptors in medulla React to high levels of carbon dioxide Receptors in lungs and muscles Provide stretch input to medulla and pons Chemoreceptors located throughout the body Stimulate respiratory centers in medulla and pons

In which primary area of the lung does carbon dioxide transfer (diffusion) occur? Nose Alveoli Trachea Bronchioles

Alveoli

Which factors affect respirations? Select all that apply. Exercise Appetite Diseases Fear Acid-base balance

Exercise Diseases Fear Acid-base balance

Which questions would the nurse ask before taking a patient’s respirations? Select all that apply. Have you exercised within the last 30 minutes? Do you vape? Have you taken any pain medication? Do you have any shortness of breath? Have you had anything cold to drink?

Do you vape? Have you taken any pain medication? Do you have any shortness of breath?

Match the respiratory rate to its corresponding age group. Newborn 1-year-old 6-year-old Older adult Answer choices 15–20 20–24 24–38 22–30

Newborn 24-38 1-year-old 22-30 6-year-old 20-24 Older adult 15-20

Which breathing pattern would the nurse suspect when a patient is breathing 8 breaths/min? Hyperventilation Tachypnea Bradypnea Apnea

Bradypnea

Which observation would the nurse observe in a patient who has Cheyne-Stokes respirations? Absence of breathing Respirations that are deep, exaggerated, regular, and increased in rate Rhythmic respirations, going from very deep to very shallow or apneic periods Respirations that are extremely shallow for two or three breaths, followed by an irregular period of apnea

Rhythmic respirations, going from very deep to very shallow or apneic periods

Which cues would the nurse obtain from the medical records about respiration and oxygenation? Select all that apply. Vital signs from the graphics Medication records Chronic obstructive pulmonary disease (COPD) from the history Baselines from the vital signs flow sheet Answers to questions before taking respirations

Vital signs from the graphics Medication records Chronic obstructive pulmonary disease (COPD) from the history Baselines from the vital signs flow sheet

Match the respiration hypothesis to its cause. Difficulty breathing Excess of carbon dioxide exhaled Respiratory center in the brain shuts down Alterations in patterns, rate, depth, quality, and/or rhythm Answer choices Apnea Hyperventilation Impaired Breathing Dyspnea

Difficulty breathing Dyspnea Excess of carbon dioxide exhaled Hyperventilation Respiratory center in the brain shuts down Apnea Alterations in patterns, rate, depth, quality, and/or rhythm Impaired Breathing

Which adult patient would the nurse assess first? Patient’s airway occluded Patient breathing 32 breaths/min Patient exhibiting Kussmaul breathing Patient who is hyperventilating

Patient’s airway occluded

Which goal would the nurse develop for a patient with an elevated respiratory rate? Patient’s respiratory rate improves. Patient’s respiratory rate will return to expected levels 1 hour after treatment. Patient will be taught to use pursed-lip breathing. Patient’s oxygen saturation level will decrease.

Patient’s respiratory rate improves.

Which finding would indicate to the nurse that an adult patient with Hyperventilation is improving? Respiratory rate decreasing Regular respirations on a ventilator Breaths increasing Lightheadedness increasing

Respiratory rate decreasing

Which finding would alert the nurse that an adult patient with dyspnea is declining? Respiratory rate of 18 Oxygen saturation 96% Painless respirations Accessory muscle use increasing

Accessory muscle use increasing

Which actions would the nurse take for a disoriented patient who “can’t catch a breath” and has a respiratory rate of 32? Select all that apply. Lower the head of the bed. Apply prescribed oxygen. Offer emotional support. Reorient patient. Monitor vital signs every 4 hours.

Apply prescribed oxygen. Offer emotional support. Reorient patient

Which breathing pattern would the nurse assess for in a patient who has a fever, anxiety, and a respiratory disorder? Bradypnea Tachypnea Hypoventilation Kussmaul breathing

Tachypnea

Which alterations would the nurse anticipate in an older adult patient who is having shortness of breath, can only breathe if in a sitting position, and has a current respiratory rate of 28? Select all that apply. Eupnea Apnea Dyspnea Tachypnea Orthopnea

Dyspnea Tachypnea Orthopnea

Which oxygen saturation sites would the nurse select for an adult patient who has decreased perfusion in the fingers and hand? Select all that apply. Finger Earlobe Foot Nose Toe

Earlobe Nose Toe

Which expected outcome would the nurse develop for a patient with altered respiration and oxygenation? Patient is able to perform activities with some shortness of breath. Patient demonstrates regular rate and depth of respirations before discharge. Patient demonstrates irregular breathing after treatment. Patient will have a respiratory rate between 12 and 20 breaths/min.

Patient demonstrates regular rate and depth of respirations before discharge.

What respiratory rate would the nurse document for a rate of 12 breaths in 30 seconds? Record your answer as a whole number. ____ breaths/min

Which actions to improve oxygenation would the nurse take for a patient who has dyspnea, confusion, lung secretions, and hypoxia? Select all that apply. Reposition the patient to a sitting position. Suction the patient’s airway. Apply prescribed supplemental oxygen to the patient. Encourage the patient to use accessory muscles. Reposition the pulse oximeter on the patient’s finger

Reposition the patient to a sitting position. Suction the patient’s airway. Apply prescribed supplemental oxygen to the patient

Which technique would the nurse use to obtain a patient’s respiratory rate? Tell the patient, “I am here to count your respirations.” Count inhalation and exhalation as one breath. If respirations are irregular, count for 30 seconds. Remove hand from patient’s wrist.

Count inhalation and exhalation as one breath.

Which factors would the nurse consider are causing a patient’s tachypnea? Select all that apply. Afebrile A smoker Reports of chest pain Receiving bronchodilators Cardiovascular disease

A smoker Reports of chest pain Cardiovascular disease

What is the expected respiratory rate (breaths per minute) for an adult patient? Record your answers as whole numbers separated by a hyphen. ___ breaths/min

12-20

Which patient respiratory rates (breaths/minute) would the nurse report as unexpected (abnormal)? Select all that apply. Newborn: 30 15-year-old: 26 Older adult: 10 Adult: 28 1-year-old: 50

15-year-old: 26 Older adult: 10 Adult: 28 1-year-old: 50

Which hypothesis would the nurse select for a patient who has ascites, painful breathing, and a subjective feeling of shortness of breath? Apnea Dyspnea Hyperventilation Impaired Breathing

Dyspnea

Which information would the nurse share with a patient who has rapid, deep breaths, feels faint, and has tingling in fingers? Inhale through pursed lips. Take slow, shallow breaths. Try to make the abdomen move out during inhalation. Use this continuous positive airway pressure mask.

Try to make the abdomen move out during inhalation.

Which cues would the nurse categorize as irrelevant for a patient’s respiration and oxygenation? Select all that apply. Has an irregular, increased respiratory rate Had prostate surgery 7 years ago Has trained intensively to run cross country Has been a teacher for 25 years Has a history of diabetes

Had prostate surgery 7 years ago Has been a teacher for 25 years

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Patient with cessation of breathing and no pulse Patient with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 90% Patient with a respiratory rate of 8 Patient with Kussmaul breathing

Patient with cessation of breathing and no pulse Patient with a respiratory rate of 8 Patient with Kussmaul breathing Patient with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 90%

Which parameter would the nurse assess to determine quality of respirations? Whether respirations are regular or irregular Whether respirations are shallow or deep Whether respirations are labored or nonlabored Whether respirations are above or below expected ranges

Whether respirations are labored or nonlabored

Which action would the nurse take for a patient with apnea who is not responding to treatment? Teach diaphragmatic breathing. Assist with placement on a ventilator. Consult an occupational therapist. Monitor respiratory rate every 2 hours.

Assist with placement on a ventilator.

Which conditions would prompt the nurse to observe for Cheyne-Stokes respirations? Select all that apply. Increased intracranial pressure Impending death Diabetic ketoacidosis Meningitis High altitude

Increased intracranial pressure Impending death

Trace the sequence of events that occurs during the oxygen transport cycle. Oxygen is released to the body’s cells. Oxygen is breathed into the lungs. Oxygen is perfused through the arteries. Oxygen diffuses across the alveoli. Oxygen binds to hemoglobin.

Oxygen is breathed into the lungs. Oxygen diffuses across the alveoli. Oxygen binds to hemoglobin. Oxygen is perfused through the arteries. Oxygen is released to the body’s cells.

Which actions would the nurse take when finding the following respiratory rates on the flow sheet: 20, 16, 12? Select all that apply. Reassess respiratory system. Perform a head-to-toe assessment. Review medications. Notify the health care provider. Monitor respiratory rate every 4 hours. Obtain an oxygen saturation measurement.

Reassess respiratory system. Perform a head-to-toe assessment. Review medications. Notify the health care provider. Obtain an oxygen saturation measurement.

Which finding would alert the nurse a newborn with impaired breathing is declining? Nasal flaring Pink skin SpO2 95% Respiratory rate 35

Nasal flaring

Which outcome would the nurse develop for a patient experiencing bradypnea? Patient will exhibit an expected respiratory rate within 1 hour of treatment. Patient will maintain respiratory rate for the next 8 hours. Patient will maintain skin color, oxygen saturation level, and orientation level at the follow-up appointment. Patient will exhibit adequate respiration and oxygenation levels.

Patient will exhibit an expected respiratory rate within 1 hour of treatment.

Match the breathing pattern the nurse would report for each patient. Patient with rapid, deep, regular respirations Patient with two or three shallow breaths followed by apnea Patient with decreased respiratory rate Patient with pattern of deep to shallow to apneic periods that repeats Answer choices Biot breathing Kussmaul breathing Cheyne-Stokes respirations Bradypnea

Patient with rapid, deep, regular respirations Kussmaul breathing Patient with two or three shallow breaths followed by apnea Biot breathing Patient with decreased respiratory rate Bradypnea Patient with pattern of deep to shallow to apneic periods that repeats Cheyne-Stokes respirations

Which factors can compromise an oxygen saturation reading? Select all that apply. Jaundice Respiratory rate Peripheral edema Some fingernail polishes Cold or injury to extremities

Jaundice Peripheral edema Some fingernail polishes Cold or injury to extremities

Which information is accurate about blood pressure? Blood pressure is measured by subtracting the diastolic from the systolic pressure. The numerator is the diastolic pressure. Blood pressure is the force against the venous walls. The heart exerts maximum pressure during contractions.

The heart exerts maximum pressure during contractions.

Match the blood vessel or mechanism of blood pressure regulation to its function. Controls delivery of blood to organs, tissues, and cells Manages mechanisms used for short-term blood pressure regulation Allows a continuous flow of blood into capillaries Releases in response to low blood pressure to retain water Answer choices Arterioles Antidiuretic hormone Arteries Autonomic nervous system

Controls delivery of blood to organs, tissues, and cells Arteriole Manages mechanisms used for short-term blood pressure regulation Autonomic nervous system Allows a continuous flow of blood into capillaries Arteries Releases in response to low blood pressure to retain water Antidiuretic hormone

Which factors increase blood pressure? Select all that apply. Shock Head injury Weight gain Vasodilation Acute pain

Head injury Weight gain Acute pain

Which area is the most common site for a blood pressure measurement? Wrist Lower leg Upper leg Upper arm

Upper arm

Which questions would the nurse ask the patient before measuring blood pressure? Select all that apply. Are you in pain? Do you feel stressed? Have you exercised within the past 5 minutes? Have you consumed any caffeine in the last 30 minutes? Have you been to physical therapy within the past 15 minutes? Do you continuously monitor your blood glucose levels with a device on your arm?

Are you in pain? Do you feel stressed? Have you consumed any caffeine in the last 30 minutes? Have you been to physical therapy within the past 15 minutes? Do you continuously monitor your blood glucose levels with a device on your arm?

Which blood pressure measurement is an unexpected finding? Newborn: 70/40 6-year-old: 90/60 15-year-old: 110/68 Adult: 128/84

Adult: 128/84

Match the blood pressure measurement to its classification. Hypertension stage 1 Elevated Hypertension stage 2 Answer choices <80 diastolic with systolic 120–129 <120 systolic 130–139 systolic ≥90 diastolic

Hypertension stage 1 130–139 systolic Elevated <80 diastolic with systolic 120–129 Hypertension stage 2 ≥90 diastolic

Which cue would alert the nurse that a patient may be experiencing orthostatic hypotension? Patient feels faint upon position change. Blood pressure increases when patient stands. Patient experiences paralysis in legs. Blood pressure remains constant during transfers.

Patient feels faint upon position change.

Which action would the nurse take to obtain patient observation cues to determine blood pressure alterations? Question the patient. Review the patient’s blood pressure on the graphic. Check the patient’s medication record. Read the patient’s history in the chart.

Question the patient.

Match the hypothesis to its pathophysiologic cause. Hypovolemia and decreased cardiac output Peripheral vasodilation with no compensation Thickened arteries that reduce compliance Answer choices Hypotension Postural hypotension Hypertension

Hypovolemia and decreased cardiac output Hypotension Peripheral vasodilation with no compensation Postural hypotension Thickened arteries that reduce compliance Hypertension

Which patient situation would the nurse assess first? Absence of breathing Hypotension Hypertension Orthostatic hypotension

Absence of breathing

Which outcome would the nurse develop for a patient with hypotension? Patient’s low blood pressure resolves. Patient’s vital signs will be within expected ranges. Patient’s blood pressure will return to expected ranges 2 hours after treatment. Patient will return to previous levels of functioning.

Patient’s blood pressure will return to expected ranges 2 hours after treatment.

Which finding alerts the nurse that a patient with hypertension is improving? Salt intake increases. Weight increases. Nose bleeds decrease. Exercising decreases.

Nose bleeds decrease.

Which action would the nurse take for a patient with hypotension? Apply oxygen. Increase salt intake. Restrict fluid. Ambulate patient.

Apply oxygen.

Which patient care strategy would the nurse take for a patient with worsening orthostatic hypotension? Emphasize the importance of restricting fluids. Perform a head-to-toe assessment. Review the white blood cell count. Prepare to transfer to intensive care unit.

Perform a head-to-toe assessment.

Which description would the nurse use when discussing stroke volume? The elasticity of the arterial system The amount of pressure in the arteries in between beats The numeric difference between systolic and diastolic pressure The amount of blood injected into the arterial system with each heartbeat

The amount of blood injected into the arterial system with each heartbeat

Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock? Select all that apply. Clammy skin Thready pulse Increased urinary output Confusion Bradycardia

Clammy skin Thready pulse Confusion

Which statements indicate the nurse understands possible errors in blood pressure assessment? Select all that apply. “A noisy environment can cause a false low reading.” “If the cuff is too wide, a false high reading is possible.” “If pressure is released too slowly, a false high reading is possible.” “A patient’s arm should be above heart level to avoid a false low reading.” “Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.”

“A noisy environment can cause a false low reading.” “If pressure is released too slowly, a false high reading is possible.” “Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.”

Which factor would the nurse suspect is causing the blood pressure to fall when a patient who experienced a myocardial infarction (heart attack) is becoming cool and clammy? Extreme vasodilation Increased blood volume Decreased cardiac output Increased peripheral vascular resistance

Decreased cardiac output

Match the type of hypertension to its description. No known cause Caused by a specific disease Systolic blood pressure over 140 Diastolic blood pressure 80–89 Answer choices Hypertension stage 3 Hypertension stage 1 Primary hypertension Hypertension stage 2 Secondary hypertension

No known cause Primary hypertension Caused by a specific disease Secondary hypertension Systolic blood pressure over 140 Hypertension stage 2 Diastolic blood pressure 80–89 Hypertension stage 1

Which action by the nurse when caring for a patient with a left mastectomy would cause the charge nurse to intervene? Takes the blood pressure in the left arm Uses a cuff width that is 40% of the circumference of the arm Listens for the first Korotkoff sound to record as the systolic pressure Makes sure the cuff bladder is 60% to 80% of the arm circumference

Takes the blood pressure in the left arm

Which interventions would the nurse implement to help an obese adult patient who smokes cigarettes successfully manage hypertension? Select all that apply. Arranging for nutritional support Encouraging cessation of smoking Monitoring responses to prescribed antihypertensive medications Comparing current blood pressure readings to original readings Listening while the patient expresses gratitude for care

Arranging for nutritional support Encouraging cessation of smoking Monitoring responses to prescribed antihypertensive medications

Which site would the nurse use to measure blood pressure when the patient’s upper body is severely burned? Popliteal Brachial Radial Femoral

Popliteal

Which adult patient’s blood pressure reading would the nurse realize is unexpected? 100/60 116/78 96/64 to 118/74 108/70 to 118/79

96/64 to 118/74

What is the patient’s pulse pressure (mm Hg) when the blood pressure is 130/70? Record your answer as a whole number. __ mm Hg

Which actions would the nurse take when manually measuring the patient’s brachial blood pressure? Select all that apply. Deflate cuff at a rate of 2 mm Hg/second. Inflate cuff 30 mm Hg above the previous systolic reading. Place cuff loosely around the upper arm. Position cuff 2.5 cm (1 inch) above the antecubital fossa. Allow the patient to sit and cross legs.

Deflate cuff at a rate of 2 mm Hg/second. Inflate cuff 30 mm Hg above the previous systolic reading. Position cuff 2.5 cm (1 inch) above the antecubital fossa.

For which patients would the nurse measure blood pressure with an electronic device? Select all that apply. Has a regular heartbeat Is shivering Experiences seizure activity Has a previous systolic blood pressure reading of 86 mm Hg Has a previous systolic blood pressure reading of 140 mm Hg

Has a regular heartbeat Has a previous systolic blood pressure reading of 140 mm Hg

Which patient cue would the nurse identify as relevant for blood pressure? Reports blurred vision Is married Had abdominal surgery 5 years ago Has periods of intense hunger

Reports blurred vision

Which information would the nurse share with a team member about the pathophysiology of hypertension? Vasoconstriction causes blood to pool in the lower extremities, making the heart pump harder. Enlarging of the blood vessels with no rise in cardiac output leads to increased blood pressure. Narrowing of the arteries causes decreased peripheral resistance, leading to higher blood pressure. Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.

Overstimulation of angiotensin and aldosterone causes the blood pressure to increase.

Place the adult patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. Patient with chronic hypertension Patient with an occluded airway Patient who has a blood pressure of 76/40 Patient with blood pressure of 110/64

Patient with an occluded airway Patient who has a blood pressure of 76/40 Patient with chronic hypertension Patient with blood pressure of 110/64

Which hypothesis would the nurse select for a patient with a blood pressure of 130/70 who when sitting up becomes dizzy and the blood pressure is 108/60? Shock Postural hypotension Hypertension stage 1 Hypotension

Postural hypotension

Which actions would the nurse take for a patient with low blood pressure from decreased peripheral vascular resistance? Select all that apply. Administer prescribed antihypertensive medications. Administer prescribed intravenous (IV) fluids. Administer prescribed oxygen. Position supine with legs elevated. Position prone with head on small pillow.

Administer prescribed intravenous (IV) fluids. Administer prescribed oxygen. Position supine with legs elevated.

Which factor would the nurse consider is likely causing hypertension in an older adult female who is 5’4”, weighs 100 lbs (45.4 kg), drinks an occasional glass of red wine before bed, and limits salt in her diet? Age Obesity Alcohol use Salt intake

age

Which finding would alert the nurse that a patient with a blood pressure of 80/40 is improving? Skin becomes warm and dry. Blood pressure decreases. DASH diet is consumed. Stress level decreases.

Skin becomes warm and dry.

Which actions would the nurse take for a patient with the following blood pressures: 119/74, 125/78, 130/83, and 135/88? Select all that apply. Measure oxygen saturation level. Monitor blood pressure every 4 hours. Reassess the circulatory system. Perform a head-to-toe assessment. Notify health care provider.

Measure oxygen saturation level. Reassess the circulatory system. Perform a head-to-toe assessment. Notify health care provider.

week 9 sherpath Flashcards

(216 cards)