Chapter 15 - Potter Text Review Questions

Question 1

Your patient had an oral temperature of 38.3 C (101 F) 30 minutes ago. When you go into the room to recheck the temperature, you discover that the patient just drank a glass of cold water. What is the most appropriate action to take at this time?

1. Take the patient’s temperature by the rectal route.
2. Wait 15 minutes before retaking the patient’s oral temperature
3. Come back in 2 hours so you can stay on schedule
4. Go ahead and take patient’s oral temperature

Answer 1

2

Question 2

You are caring for a patient admitted to the medical floor 2 hours ago for dizziness and confusion. The patient took the first dose of a new blood pressure medication that lowers the heart rate. Which vital signs can you delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Temperature 2. Heart rate 3. Oxygen saturation 4. Respirations 5. Blood pressure

Answer 2

1, 3, 4

Question 3

A patient has the following vital signs: heart rate 52 beats/min, BP 80/52, respirations 14 breaths/min, oral temperature 37.1 C (98.8 F), and SpO2 98%. What is the appropriate interpretation of these vital signs?

1. Tachycardia with hypertension
2. Bradycardia with hypertension
3. Tachycardia with hypotension
4. Bradycardia with hypotension

Answer 3

4

Question 4

A patient who had surgery 8 hours ago has a blood pressure (BP) of 126/84 while lying down. The BP is 94/54 when sitting up at 1 minute. The patient states that he is light-headed, and you see that he has become pale. What is the most likely cause for the change in blood pressure?

1. Normal hypotension following surgery
2. Side effect of fluid shifts in the body following surgery
3. Orthostatic hypotension
4. Normal response to repositioning to a sitting position

Answer 4

3

Question 5

When choosing the correct blood pressure cuff for an adult patient, the nurse would take into consideration ____________ and ____________.

Answer 5

Width of the blood pressure cuff and circumference of the patient’s arm

Question 6

A newly admitted patient has a tympanic temperature of 38.8 C (102 F). What is the priority nursing intervention?

1. Obtain blood cultures after you give the first dose of antibiotic
2. Remove all the patient’s blankets and sheets and the patient’s shirt
3. Turn down the room thermostat until the patient starts shivering
4. Monitor temperature for trends in elevation

Answer 6

4

Question 7

You just started to shift and are reviewing your patients’ vital signs that were taken by the nurse assistive personnel (NAP). You note that the NAP documented lower-than-expected blood pressure (BP) readings on all your patient’s. When you retake the BP, what is the most likely reason you will find for the low pressures that were obtained previously?

1. BP cuffs were too wide for the patients’ arm circumference
2. Bladder of BP cuff was inflated and deflated too slowly
3. BP cuffs were too narrow for the patients’ arm circumference
4. BP cuff was not wrapped evenly around the patients’ arms

Answer 7

1

Question 8

When you are palpating your patient’s pulse, you note an irregular rhythm. You review the patient’s electronic health record and find that before this the patient’s pulse was regular. What is your priority action?

1. Assess your patient for a pulse deficit
2. Take an apical pulse for 15 seconds
3. Document your finding and notify the health care provider the next day if the pulse remains irregular
4. Assess your patient’s temperature

Answer 8

1

Question 9

When assessing a patient, you find that the patient is alert and oriented by the pulse obtained by the pulse oximeter is significantly less than the pulse you just took. What do you need to do first?

1. Notify the health care provider or the nurse in charge
2. Provide supplemental oxygen
3. Check the oximeter is intact
4. Assess your patient for signs and symptoms of decreased oxygenation

Answer 9

3

Question 10

A male patient is in the emergency department with nausea and vomiting. His vital signs are HR 116, BP 92/96, respiratory rate 20, pulse oximeter 94%, and tympanic membrane temperature 36.2 C (97.2 F). He is pale and diaphoretic. Which nursing interventions are appropriate in the care of this patient? (Select all that apply.) 1. Provide the patient water to prevent dehydration. 2. Dry off the skin and provide warming blanket 3. Raise the head of bed to promote oxygenation 4. Check the ear canal for cerumen (earwax) and retake temperature. 5. Ask the nursing assistive personnel (NAP) to retake the patient’s blood pressure

Answer 10

2, 3