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A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?
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The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?
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foundation ch.25
| Question | Answer |
|---|---|
| A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? | "It is because of the immature ability to regulate temperature in general." |
| The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? | deep in the posterior sublingual pocket |
| The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? | apical |
| The nurse has completed an assessment and notes that the client’s blood pressure is 132/92 mmHg. What is this client’s pulse pressure? | 40 mmHg |
| A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? | Rectum |
| A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: | decrease the apical pulse. |
| Which client's blood pressure best describes the condition called hypotension? | The systolic reading is below 100 and diastolic reading is below 60. |
| A client reports feeling “different” than earlier in the day. When would the nurse anticipate assessing vital signs? | immediately |
| The nurse has just measured an adult client’s oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, “I just finished my coffee right before you came in. Can I have another cup?” Which response by the nurse is most appropriate? | I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return.” |
| An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading? | advanced age |
| A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: | decrease the apical pulse. |
| A client has smoked most of his life and has labored respirations. He is experiencing: | dyspnea |
| A nurse is assessing the blood pressure of an adult client using the Korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document blood pressure measurements in the client? | Phase IV |
| A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? | Auscultate the lung sounds and count respirations. |
| When taking the client's temperature, the student nurse will require further education when they state | "The axillary route is the most accurate of all routes." |
| The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? | Use the Doppler ultrasound device. |
| When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? | The client's pulse rate is below 60 beats per minute. |
| A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? | “Dizziness when you change position can occur when fluid volume in the body is decreased.” |
| The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as: | orthopnea |
| A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? | A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? |
| The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: | increased temperature. |
| When assessing an infant's axillary temperature, it will be: | 1°F (0.5°C) lower than an oral temperature. |
| A person's core body temperature is highest in the early morning and lowest in the late afternoon. T or F? | False |
| Which action is acceptable for the nurse to perform when assessing blood pressure? | Raise the client’s arm over the head for 30 seconds to help relieve congestion of blood in the limb and make the sounds louder and more distinct. |
| A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next? | Write it down |
| A nurse is assessing an adult client’s blood pressure. How should the nurse estimate the client’s systolic blood pressure (SBP)? | Inflate the blood pressure cuff while palpating the client’s brachial artery. |
| A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? | Pulse is felt with difficulty and disappears with slight pressure. |
| Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? | 1700 |
| The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? | apical |
| Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? | palpation of the radial pulse on the thumb side of the inner aspect of the wrist. |
| Which piece of equipment is no longer used for temperature measurement? | glass mercury thermometer |
| A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply. | respiratory rate 30/min headache red or flushed skin |
| A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? | Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. |
| The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention? | rectal |
| The nurse is attempting to assess a client’s radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? | Assess the apical pulse. |
| Which term indicates a potentially serious client condition? | pyrexia |
| The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this? | The client is covered with a couple of thick blankets. |
| The nurse is caring for a newborn with bluish nails and lips, rapid respirations, sweating, and having difficulty feeding. Which considerations should the nurse use when assessing the blood pressure to screen for potential cardiac problems? | Assess blood pressure in upper extremities. Assess blood pressure in lower extremities. If the diastolic blood pressure continues to “0,” document as the reading/P for “pulse.” |
| The nurse has palpated the client’s radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse’s most appropriate action? | Auscultate the client’s apical heart rate. |
| A pulse deficit is the difference between: | the apical pulse and the radial pulse rates. |
| A nurse records a pulse rate of 170 beats/min on a client’s electronic health record. For which client would this be considered a normal assessment finding? | a healthy newborn infant |
| A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client? | Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. |
| A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next? | Write it down |
| A nurse is assessing a client’s blood pressure manually. The nurse should identify the client’s systolic blood pressure (SBP) when which event occurs? | The first faint, but clear, sound appears. |
| A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? | the ability of the arteries to stretch |
| A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply. | encourage oral fluid intake encourage slow movement from the bed to the chair encourage the client to use the call light prior to getting out of bed encourage the use of the call light for help to the bathroom |
| The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply. | The client has reports of pain of 8 on a scale of 0 to 10 The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C) |
| An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? | auscultate the client's apical pulse |
| The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? | Lightly compress the client’s radial artery using the first, second, and third fingers. |
| Which statement describes diastolic blood pressure? | During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. |
| Which guideline should the nurse follow when assessing a client’s blood pressure using a Doppler ultrasound? | Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. |
| The nurse has completed an assessment and notes that the client’s blood pressure is 132/92 mmHg. What is this client’s pulse pressure? | 40 mmHg |
| A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? | No stethoscope is required. |
| The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: | fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. |
| A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? | The client’s most recent temperature |
| The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing? | diminished, weaker than expected |
| The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? | Inflate the cuff about 30 mm Hg above the auscultatory gap. |
Created by:
briannagrace