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Foundations Nursing
Foundations Nursing set 4
| Question | Answer |
|---|---|
| Which measurements are included in vital sign assessment? | Pulse *Respiration *Temperature *Blood Pressure |
| When is vital sign measurement for a stable hospitalized patient typically taken? | *Every 4 to 8 hours |
| During which situations is vital sign assessment required? | *In ongoing care *During an inpatient stay *Before and after surgery *As part of a physical assessment |
| Which factors influence the interpretation of vital signs? | *Medications *Medical history *Emotional state *Physical environment |
| What actions must the nurse take before delegating vital sign assessment to unlicensed assistive personnel (UAP)? | *Assess the patient. *Determine the patient to be medically stable. *Verify the UAP uses the proper technique for measuring vital signs. *Ensure the UAP knows what values need to be reported immediately for each patient. |
| Which vital sign functions might the nurse delegate to unlicensed assistive personnel (UAP)? | *Report vital signs for a stable patient. *Measure vital signs for a stable patient. |
| Which duties are strictly nursing responsibilities? | *Interpret vital sign data. *Reassess any abnormal values measured by the UAP. *Assess patients to determine whether they are medically stable. Report abnormal values to the appropriate health care provider |
| Which actions are requirements for proper documentation? | *Documenting on the specified form *Documenting in a standardized format *Recording normal and abnormal vital sign results |
| Which elements are included in proper vital sign documentation? | *Date of assessment *Time of assessment *Numerical results of assessment *Name and clinical designation of staff making assessment |
| Which benefits for patient care result when a nurse uses informatics? | Navigation of the electronic health record allows the nurse to view baseline data. *Technology that supports clinical decision-making is understood by the nurse. *Data are accessible in a common database from multiple locations. |
| The student nurse is learning about vital signs. Which measurements are included in vital sign assessment? | *Pulse *Blood pressure *Respiration rate *Oxygen saturation |
| The nurse is teaching a student nurse about vital signs. Which patient response shows teaching has been effective? | "Blood pressure is the measurable pressure of blood within the systemic arteries." |
| In which patients would pulse oximetry most likely be utilized? | An older adult with hypoxemia A patient with community-acquired pneumonia *A teenager having an asthma attack with oxygen saturations of less than 92% in air An adult patient in the outpatient clinic who has a history of (COPD) |
| 21-year-old college football player in hospital 24 hours for observation following concussion. His (BP) stable at 118/62 mm Hg, suddenly complains of a severe headache and his BP is 170/94 mm Hg. The nurse orders vital sign monitoring with what frequency? | *Every 5 minutes |
| The nurse receives a 50-year-old patient back from the endoscopic department. The patient had conscious sedation for an esophageal biopsy. When should the nurse take vital signs? | *Monitor vital signs every 15 minutes for 1 hour; then if stable, every hour for 2 hours. |
| 82-year-old 2 days postop right hip replacement. patient comorbidities: hypertension, atrial fib, and type 2 diabetes. patient scheduled for transfer to rehab later today. Vital signs stable since surgery. How often should patient’s vital signs monitored? | *Vital signs need to be monitored at the time of morning care and again 1 hour before transfer. |
| 35-year delivered 9 lb, 7 oz 24 hours ago cesarean. vital signs stable,74 bpm, temp 99°F, 4 hours ago. The (UAP) reports pulse now 100 bpm, temp 101.8°F, complaining of chills. room temp 73°F. nurse interprets data takes which action? | *Assess the patient. |
| nurse ready to give 60-year-old daily cardiac medication. The certified nursing assistant (CNA) reports that the patient's vital signs are pulse 42 bpm, blood pressure 148/86 mm Hg, and respirations 20 bpm. What interpretation will the nurse make? | *Withhold the cardiac medication.. *Recheck the patient's vital signs. *Compare the current vital signs with this patient's baseline data. |
| A 6-year-old child is carried into the ER by the mother. The child has a history of asthma and is gasping for breath and wheezing. The child’s vital signs are respirations 30 bpm, pulse 120 bpm, SpO292%, and BP 90/50 mm Hg. The nurse takes which actions? | *Obtain o2 *Call for the appropriate care provider to quickly evaluate. *Ask the mother for a medical history, including any medications. *Initiate standing protocols for childhood asthma until the appropriate care provider arrives. |
| charge nurse in AL arrived NOC shift. report, nurse told res fell room 2 hrs ago. nurse called DR, patient to be observed unless complains pain. charge making shift assignment (UAP) this evening. Which parameters nurse consider when assigning UAP? | UAP obtain vital sign patient fully conscious and aware surroundings patient has had a continuous drop in blood pressure since fall. patient asks to have UAP provide care because have good relationship. patient has continuous drop in bp since fall. |
| The nurse is making the daily assignment on the unit. There is an unlicensed assistive personnel (UAP) available to assist with patient care. Which action is the responsibility of the nurse? | *Interpret vital sign data collected. *Reassess any abnormal values measured by the UAP. *Ensure the UAP uses the proper tech¬nique for measuring vital signs. *Ensure the UAP knows what values need to be reported immediately for each patient. |
| The nurse working on a busy postoperative floor is making the daily assignment for an experienced unlicensed assistive personnel (UAP) on this unit. Which aspects should the nurse consider regarding delegation? | *Nurses responsible reassessing & reporting abnormal vital signs *Nurses may delegate vital signs after determining patient is stable. *Nurses ensure that UAP competent to perform vital sign assessments, knows values that must be reported immediately. |
| The (UAP) reports the current vital sign assessment on a patient who is on the third recovery day after a fractured femur: BP 156/92 mm Hg, P 84 beats per minute, R 18 beats per minute, and T 98.8°F. The nurse takes which actions? | Review the patient’s vital sign history. Review the patient’s medical history. Verify the vital signs personally. |
| Which actions taken by the nurse when documenting vital signs support the goal of efficient and safe patient care? | Document in a standardized format. *Format to easily identify the patient's vital sign trends. *Provide multiple sets of vital signs visible at a time. *Communicate with all members of the health care team. |
| Which factors influence the interpretation of vital signs? | *Patient status *Patient's unique medical condition *Standard range for vital sign values *Consideration of patient's baseline vital signs |
| What is respiration? | Respiration is the mechanism by which oxygen and carbon dioxide are exchanged between the outside of the body and the blood and further exchanged between the blood and cells. |
| Match the mechanism of involuntary breathing control with the corresponding action. | React to hypoxemia-Chemoreceptors aortic arch, carotid arteries /React high levels of carbon dioxide (hypercapnia), changes in pH-Receptors in medulla |
| Which statement describes dyspnea? | Difficult or labored breathing Dyspnea is difficult or labored breathing. It can also be a rapid, shallow pattern of breathing that is painful. |
| Match the mechanism of involuntary breathing control with the corresponding action. | Provide input to medulla, pons-Stretch receptors in lungs, muscles / Stimulate respiratory centers in medulla, pons-Chemoreceptors throughout body |
| Which range reflects normal values for oxygen saturation? | 95-100% |
| Which factors can compromise a pulse oximetry reading? | cold, jaundice, peripheral, nail polish |
| Tachypnea | Breathing rate increased (>24 bpm), with quick shallow breaths Fever, exercise, anxiety, respiratory disorders |
| Bradypnea | Breathing rate abnormally slow (<10 bpm) Increased intracranial pressure, brain damage, medications that depress respiratory center |
| Hyperventilation | Overexpansion of the lungs, characterized by rapid and deep breaths Extreme exercise, fear, anxiety, diabetic ketoacidosis, aspirin overdose |
| Hypoventilation | Underexpansion of the lungs, characterized by shallow, slow respirations Drug overdose, head injury |
| Cheyne-Stokes Respirations | Rhythmic respiration, going from very deep to very shallow or apneic periods Heart failure, renal failure, drug overdose, increased intracranial pressure, impending death |
| Kussmaul’s Breathing | Respiration abnormally deep, regular, and increased in rate Diabetic ketoacidosis |
| Apnea | Absence of breathing for several seconds Respiratory distress, obstructive sleep apnea |
| Biot’s Breathing | Respiration abnormally shallow for two or three breaths, followed by irregular period of apnea Meningitis, severe brain injury |
| Which statement describes why arterial blood gases are used in patient assessment? | to obtain base line |
| Which step should be performed first in a respiratory assessment? | focused interview |
| When assessing a patient’s lung sounds, the nurse should keep in mind that the right lung has how many lobes? | 3 |
| Where should the nurse auscultate for vesicular or alveolar breath sounds? | Posterior lower lobes |
| A nurse assessing a patient suspects moderate to severe hypoxia. Which oxygen saturation range would indicate this condition? | 85-89% |
| Which nursing diagnoses are examples related to ventilation and oxygenation? | Activity intolerance Ineffective airway clearance Anxiety Ineffective breathing pattern Impaired gas exchange Acute pain Ineffective peripheral tissue perfusion |
| Which nursing diagnoses are appropriate initially for a patient in the emergency department who “can’t catch a breath?” | Ineffective breathing pattern, Impaired gas exchange, |
| Which goal is appropriate initially for a patient in the emergency department who “can’t catch a breath?” | Patient will exhibit regular breathing pattern with ambulation to the bathroom and back within 24 hours. |
| Which example provides a realistic goal for a patient with altered ventilation and oxygenation? | will breathe without difficulty while undergoing oxygen therapy. will develop and maintain an effective breathing pattern before discharge to home. will verbalize understanding of how to safely implement oxygen therapy upon discharge to home. |
| Which desired outcome is appropriate for a patient with altered ventilation and oxygenation? | is able to perform ADLs without becoming short of breath. states he has decreased shortness of breath and fatigue (tiredness). demonstrates normal rate and depth of respirations. demonstrates symmetrical chest excursion. states his sleep is improved. |
| The cerebral cortex of the brain allows voluntary control of breathing. When a patient sings, to which aspect do the receptors in the medulla react? | changes in pH high levels of carbon dioxide |
| Which statement describes ventilation? | Movement of oxygen and carbon dioxide in and out of the lungs, or inhaling and exhaling |
| Which value represents an acceptable respiratory rate for a 15-year-old patient? | 15,18 |
| frail older adult who is experiencing shortness of breath is only able to breathe laying on the right side. The patient has a current respiratory rate of 28 breaths per minute (bpm). Which terms describe the signs and symptoms the patient is exhibiting? | c. dyspnea d. orthopnea e. tachypnea |
| The student nurse is discussing arterial blood gases (ABGs) with the instructor. Which statement made by the nurse reflects the student needs further education? | Nurses do not draw ABGs. |
| An older adult patient has very poor perfusion in the fingers. Which location should the nurse use to measure oxygen saturation? | toe nose earlobe |
| The nurse is assessing the patient’s ventilation status. Which features will the nurse assess? | chest rise respiratory rate lung compliance |
| The nurse is caring for a patient diagnosed with a head and brain injury. Which alterations in breathing pattern could possibly occur? | hypoventilation biot's breathing Cheyne-Stokes respirations |
| During the respiratory assessment, the nurse hears “wheezes.” Which type of sound is the nurse hearing? | whistling |
| Which percentage reflects a normal value for SvO2? | 70% |
| The nurse obtains an arterial blood gas (ABG) on a patient and the pH is 7.33 and the PaO2 is 103. Which action should the nurse take? | Call the health care provider because these results are abnormal. |
| nurse in ER patient presents: 65-year-old complains of shortness of breath, in tripod position, skin pale, 42 bpm, blood pressure 152/95 mm Hg, and a history of chronic obstructive pulmonary disease (COPD). Which objective data can the nurse obtain? | pale skin color History of COPD High blood pressure |
| The nurse has a patient who was admitted 24 hours ago for asthma exacerbation. The patient is currently on 8 liters high flow oxygen with respiratory treatments every 2 hours. Which statement reflects a realistic goal for this patient? | The patient will demonstrate the ability to complete all activities of daily living with no increase in dyspnea before discharge |
| Which aspects would the nurse measure to assess respiration and ventilation? | Respiratory rate Respiratory depth Respiratory rhythm |
| A student nurse is learning about altered oxygen saturation levels. Which statement indicates further teaching is needed? | "Nose bleeds are caused by altered oxygenation levels." |
| Which is an initial nursing action for a patient having shortness of breath? | Assess pulse oximeter for O2 saturation levels. |
| Which factors affect body temperature? | stress hormones environment |
| Infants under the age of _________ months have immature regulatory mechanisms, causing constant body temperature instability. | 3 |
| Which situations require assessment of a person’s temperature? | spinal cord injury cognitive impairment altered level of consciousness |
| Which part of the human brain maintains a consistent internal body temperature despite environmental extremes? | Hypothalamus |
| A nurse is examining a patient in the ER who presents with symptoms of heat exhaustion and has a temperature of 102.9°F. The nurse feels the patient’s wet skin and observes the patient shivering. Which action should the nurse take first? | Give the patient intravenous fluids to replace lost electrolytes. |
| Which parts of the human body are most vulnerable to frostbite? | -Toes -Ear lobes -Tip of nose |
| The nurse is caring for a patient with a temperature of 38.5°C. What symptoms might he or she observe? | -Shivering -Hot, dry skin -Decreased urinary output |
| Which features are signs of hypothermia? | -Drowsiness -Pale and cool skin -Decreased urinary output |
| Which range reflects a person’s normal core body temperature? | 36.5-37.5 degrees Celsius |
| Most common site for measuring temperature | oral |
| Measures core or deep tissue temperature | tympanic |
| Tolerated by infants and young children | Temporal Artery |
| These readings are very accurate, but not preferred by patients | rectal |
| Which assessment question should a nurse ask a patient before measuring temperature? | Have you exercised in the last 30 minutes? |
| Which nursing diagnosis is most appropriate for hyperthermia? | Hyperthermia related to infectious process, as evidenced by temperature of 40° C. |
| Which examples describe objective data related to thermoregulation? | The patient is shivering. -The patient has slurred speech. -The patient has a low temperature |
| Which patient goal supports bringing the body temperature back within normal range? | Patient will maintain temperature within expected parameters before discharge from the hospital. |
| Which outcome statement represents a well-written short-term goal for a hospitalized patient with an alteration in thermoregulation due to prolonged cold exposure? | Maintain temperature within normal range within 1 hour of initiation of warmed intravenous fluids. |
| A student nurse is taking the temperature of a patient at 6 p.m. and realizes that the temperature is higher than it was only an hour ago. Which statement made by the student nurse indicates effective learning? | "The temperature of most people is lowest around 3 a.m. and highest around 6 p.m." |
| nurse taking care of patient with cervical spinal cord injury. patient is quadriplegic with a C5 fracture. patient is sweating profusely and is afebrile with a temperature of 37°C. What does the nurse know about spinal cord injuries and thermoregulation? | Disease or trauma to brain or spinal cord can cause alterations in temp control. Quadriplegics cannot change circumstances to adjust temperatures due to motor limitations. spinal cord injury can feel cold, even though core temp may be normal. |
| While taking the temperature of a patient the nurse learns that the patient exercised before arriving at the appointment. Which explanation describes why the nurse assumes the temperature reading will not reflect an accurate body temperature? | Body temperature increases with exercise. |
| The nurse would expect a patient to have alterations in temperature control if experiencing which event? | Being admitted to the hospital after experiencing trauma to the neck |
| novice nurse treats a patient using heat therapy for a back injury. Afterward, the nurse takes the patient’s temperature using the oral method and notices that it is high. Which action made by the novice nurse indicates the need for additional training? | The nurse should have measured the temperature prior to providing heat application. |
| Exposure to extreme cold, resulting in low body temperature. | hypothermia |
| Ice crystals form inside cells, causing permanent tissue damage. | frostbite |
| Rise in body temperature above normal, caused by trauma or illness. | fever |
| High body temperature, caused by prolonged exposure to extreme heat. | hyperthermia |
| A registered nurse is assessing a patient with decreased respirations, cool skin, and decreased muscle coordination. Which action made by the nurse supports the nursing diagnosis of hypothermia? | Takes the patient’s blood pressure, which shows hypotension |
| The nurse is educating a student nurse about appropriate sites to assess temperature. Which statement made by the student nurse indicates the need for further teaching? | "I can get an accurate temperature reading by placing the thermometer to the right of the patient's axilla." |
| The nurse is teaching a class on appropriate temperature assessment questions. Which statement made by the student nurse shows that the teaching has been effective? | "I will ask the patient if he has been sleeping well." |
| A student nurse is describing the process of taking a patient’s temperature to the charge nurse. Which statement made by the student nurse indicates teaching has been effective? | "I must determine the patient's baseline temperature." |
| Which statement shows the proper relationship between a patient’s condition and temperature site selection? | "Because the patient has a low white blood cell count, she will not receive a rectal temperature measurement." |
| patient admitted to hospital exposed to below-freezing temp while engaging in sports in cold weather. observes patient shivering, learns not wearing proper clothes. patient weak pulse, rapid heart rate, slightly delirious. nursing diagnosis appropriate? | Hypothermia related to exposure to below-freezing temperature without adequate clothing, as evidenced by a weak pulse and rapid heart rate |
| Which statement made by the nurse shows an understanding of objective and subjective data? | -"Objective data is gathered through observation." -"Subjective data is gathered from the patient." -"Subjective data is gathered from the patient's relatives." |
| The student nurse discusses goals for thermoregulation with a patient. Which statement made by the patient shows proper understanding of treatment outcomes? | "I will have an oral temperature of 98.4 degrees F. " |
| nurse assesses patient admitted to ER with core body temp of 93.2°F, after exposed to freezing temp for long period of time. nurse feels patient’s skin, documents it is cool to touch. Which actions should nurse take to confirm diagnosis of hypothermia? | Check the patient's pulse -Observe the patient for shivering -Measure the patient's blood pressure |
Created by:
colby.caswell