Chapter 17

Question 1

The nurse observes a patient’s respirations as follows: several shallow breaths followed by 10 seconds of apnea, then several shallow breaths followed by 5 seconds of apnea. Which type of respirations is the patient experiencing?

Answer 1

BIOTS

Question 2

Which pain assessment tool is most appropriate for a 2-month-old infant?

Answer 2

FLACC SCALE

Question 3

The nurse is caring for all of the following patients. Which patient would most likely have the lowest temperature?

Answer 3

Patients temperature was taken early in the morning

Question 4

The nurse is obtaining a patient’s pulse and notices that the pulse is weak and if slight pressure is applied, this can eliminate the pulse. How should the nurse chart this finding?

Answer 4

1+ PULSE

Question 5

The nurse is assisting the registered nurse (RN) in presenting a staff educational program about blood pressure. Which statement by staff members indicates successful teaching? Select all that apply.

Answer 5

-BP can decrease from hemorrhage
-Overhydration can increase BP
-The parasympathetic nervous system lowers BP

Question 6

A patient is experiencing orthopnea. Which finding would the nurse observe when collecting data from the patient?

Answer 6

Has dyspnea unless sitting upright

Question 7

The nurse is collecting data from a patient who is febrile (Feverish). Which signs and symptoms would the nurse observe? Select all that apply.

Answer 7

-Reddened Face
-Increased pulse rate
-Decreased appetite
-Increased irritability
-

Question 8

The nurse hears in report that a patient’s heartbeat is regular irregular. How should the nurse interpret these data?

Answer 8

Pulse skips every fourth beat. (Irregular means that there is a predictable skipped beat.)

Question 9

The nurse counts the respirations for 15 seconds and gets 4. How many respirations per minute should the nurse chart on the vital signs sheet?

Answer 9

16

Question 10

The nurse is making patient care assignments. The nurse would assign the assistive personnel (AP) to take vital signs for which patient?

Answer 10

PT who is 2 days post operative.
-Must be safe and stable for AP

Question 11

A patient has a slightly elevated temperature. Which questions would the nurse ask to determine if there are factors that may have contributed to the elevated temperature? Select all that apply.

Answer 11

-Had the PT ambulated before the temperature
-Had the patient eaten a meal
-Was the patient shivering

Question 12

The nurse is taking routine vital signs on assigned patients. Which nursing action indicates a correct understanding of taking a blood pressure?

Answer 12

Take the BP using a cuff that covers two-thirds of the arm circumference

Question 13

The nurse tells a patient to call for help before getting out of bed due to postural hypotension. Which blood pressure supports this intervention?

Answer 13

Sitting BP 124/74 mm Hg, standing blood pressure 100/52 mm Hg

Question 14

The nurse is assisting with health screenings at a local health fair. Which factor would the nurse recognize as increasing the risk for hypertension?

Answer 14

Works as an air traffic controller at a local airport (high stress can increase BP)

Question 15

The nurse is caring for an adult patient with hypertension. Which action should the nurse take when taking a blood pressure?

Answer 15

Support the PTs arm at the level of the heart

Question 16

The nurse is preparing to take a patient’s blood pressure. Which action should the nurse take?

Answer 16

Use the Pts antecubital space to measure blood pressure

Question 17

The nurse is preparing to take a patient’s routine 1000 vital signs. Upon entering the room, the nurse notices the patient drinking a cup of coffee. Which action should the nurse take?

Answer 17

Take the blood pressure at 10:30
-Smoking or caffeine needs half an hour for readings

Question 18

Which actions by the nurse can cause a falsely high blood pressure reading? Select all that apply.

Answer 18

-Does not support the PTs arm
-Uses a cuff that is too small
-Applies cuff too loosely

Question 19

The nurse is taking a patient’s pulse and discovers an irregular pulse. Which action should the nurse take?

Answer 19

Count for one full minute

Question 20

The nurse is contributing to a staff education program about cardiac functioning and pulses. Which information should the nurse recommend including?

Answer 20

Cardiac output is the volume of the blood pumped from the heart in 1 minute

Question 21

The nurse is assisting the registered nurse (RN) in describing the process of inhalation and exhalation. In which sequence should the nurses explain the process, starting with inspiration?

Answer 21

1. The medulla sends an impulse to phrenic nerves
   2.The diaphragm flattens and intercostal muscles contract
   3.The chest cavity enlarges and oxygen enters
   4.The diaphragm and intercostal muscles relax
   5.The thoracic cavity shrinks, compressing lungs
   6.Carbon dioxide is returned to the atmosphere

Question 22

The nurse obtains the following vital signs: Radial pulse - 87; Apical pulse - 93; Blood pressure - 134/86. What is the pulse pressure?

Answer 22

48
-Diff between systolic and diastolic (134-86)

Question 23

Which situations would cause the nurse to take a patient’s vital signs more often? Select all that apply.

Answer 23

-PT is receiving blood
-PT BP was 120/68 and is now 100/45
-PT is unstable after hip replacement
-PT is cold and clammy

Question 24

The nurse is discussing the steps in the development of a fever to a coworker. In which sequence would the nurse describe the process?

Answer 24

1.Bacteria enters body
2.Phagocytes secretes pyrogens
3.Secretion of prostaglandin hormone occurs
4.Hypothalamus raises the set point
5.Surface vasoconstriction occurs

Question 25

The nurse auscultates a patient's chest and hears popping sounds as a result of air moving over secretions in the lungs. How would the nurse chart this finding?

Answer 25

Crackles in lower lung sounds

Question 26

A patient's blood pressure drops when changing positions. Which information would the nurse share with the patient?

Answer 26

Rise slowly to a standing position -This is their weird wording for dangle

Question 27

An adult patient's blood pressure results are 126/74, 132/72 ,and 136/76. How would this patient's blood pressure results be categorized?

Answer 27

Prehypertension -systolic of 120 -129 and diastolic less then 80

Question 28

A patient has a pulse rate of 54. Which question should the nurse ask to determine if this is a normal finding?

Answer 28

Are you an athlete

Question 29

Which patient finding would cause the nurse to suspect a decreased respiratory rate?

Answer 29

Patient is sleeping

Question 30

A patient who has an abdominal incision reports that the pain is so bad "I can hardly stand it." Which response should the nurse make first?

Answer 30

Where is the pain -Always ask where first

Question 31

The nurse is contributing to the plan of care for a patient with pyrexia (interchangeable for febrile or fever). Which interventions should the nurse recommend including in the patient's plan of care? Select all that apply.

Answer 31

-Provide additional fluid intake -Provide mouth care -Promote rest periods

Question 32

A patient's oxygen saturation readings are not consistent. The nurse begins to collect data to determine the problem. Which patient findings are possible causes for the inconsistent readings? Select all that apply.

Answer 32

-Is wearing artificial nails -Has dark painted nails -Is experiencing diaphoresis (excessive sweating) -Is restless

Question 33

One nurse is taking the apical pulse and another nurse is taking the radial pulse. The apical pulse is 92 and the radial pulse is 85. The nurse takes a patient's blood pressure and it is 112/65. What is the pulse deficit? Record the answer as a whole number?

Answer 33

7 -apical pulse minus radial pulse -92-85=7