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Flashcards in Chapt 29 questions Deck (8)
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The pt's temp at 0800 using oral electronic thermometer is 97.2 F. If the RR, Pulse, & BP were w/in normal range, what would the nurse do:

  • A: wait 15 min and retake it.
  • B: check pt's baseline
  • C: Retake using a different thermometer
  • D: chart the temp. It's normal.

B: Check pt's baseline


Which pt meets the criteria for selection of the apical site for assessment of the pulse rather than the radial pulse?

  • A: a pt's in shock
  • B: the pulse changes w/body position changes
  • C: a pt w/arrhythmia
  • D: it is less than 24 hrs since a pt's surgical operation

C: pt w/arrhythmiaapical site would determine actual cardiac rhythm of an abnormal rhythm


When the nurse enters the room to measure V/S in preparing the pt for a dx test, the pt's on the phone. What technique should the nurse use to determine the RR?

  • A: Count the RR during conversational pauses
  • B: ask the pt to end the phone call now and resume it at a later time
  • C: Wait at the pt's bedside until the phone call is over and then count RR
  • D: Since there's no evidence of distress or urgency, defer the measurement

D: since the pt's needs are always considered first, the measurement can be delayed unless the pt's distressed or if there are other urgent reasons


For a pt w/a prior BP of 138/74 & a Pulse of 64, approximately how long should the nurse take to release the BP cuff in order to obtain an accurate reading?

  • A: 10-20 sec
  • B: 30-45 sec
  • C: 1-1.5 min
  • D: 3-3.5 min

B: the cuff is inflated to about 30mmHg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid-60s mmHg at 2 to 3mmHg a second requiring 30-40 sec


When will it be appropriate to delegate the taking of V/S of which pt to UAP?

A: a pt being prepared for elective facial surgery w/a hx of HTN

B: a pt receiving a blood transfusion w/a hx of transfusion reactions

C: a pt recently started on a new antiarrhythmic agent

D: a pt who is admitted frequently w/asthma attacks

A; V/S may be delegated to an UAP if the pt's in stable condition, if the findings are expected to be predictable, and if the technique requires no modification


An 85 yo pt has had a stroke resulting in R-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are appropriate for taking the temp? select all that apply.

  • A: oral
  • B: rectal:
  • C: axillary
  • D: tympanic
  • E: temporal artery

C, D, E


A nrs dx of ineffective peripheral tissue perfusion would be validated by which of the following?

  • A: bounding radial pulse
  • B: irregular apical pulse
  • C: carotid pulse stronger on the L side than the R
  • D: absent posterior tibial and pedal pulses

D: the posterior tibial & pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals


The nurse reports that the pt has dyspnea when ambulating. the nurse is most likely to have assessed which of the following?

  • A: shallow resp
  • B: wheezing
  • C: SOB
  • D: Coughing up bld

C: dyspnea, difficulty or labored breathing is commonly related to inadequate oxygenation. Therefore, the pt is likely to experience SOBShallow resp are seen in tachypnea (rapid breathing)