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Which description would the nurse use when discussing stroke volume?
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Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock?
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Week 3 Fond of Nurse
Foundations of nursing fundamentals week 3
| Question | Answer |
|---|---|
| Which description would the nurse use when discussing stroke volume? | The amount of blood injected into the arterial system with each heartbeat Stroke volume is the volume of blood injected into the arterial system with each heartbeat (ventricles contract). |
| Which cues would the nurse observe in a patient with a blood pressure of 60/40 and shock? | Clammy skin, thready pulse, confusion |
| Which statements indicate the nurse understands possible errors in blood pressure assessment? | *A noisy environment can cause a false low reading.” *“If pressure is released too slowly, a false high reading is possible.” *“Reinflating the cuff bladder before it has completely deflated can cause a false high measurement.” |
| Which factor would the nurse suspect is causing the blood pressure to fall when a patient who experienced a myocardial infarction (heart attack) is becoming cool and clammy? | Decreased cardiac output Decreased cardiac output is a physiologic factor of hypotension and is caused by a myocardial infarction. |
| Which action by the nurse when caring for a patient with a left mastectomy would cause the charge nurse to intervene? | akes the blood pressure in the left arm The charge nurse would intervene because a brachial blood pressure is not used on the arm that is on the side of the mastectomy as this would promote lymphedema (swelling). |
| Which interventions would the nurse implement to help an obese adult patient who smokes cigarettes successfully manage hypertension? | Arranging for nutritional support, Encouraging cessation of smoking, Monitoring responses to prescribed antihypertensive medications |
| Which site would the nurse use to measure blood pressure when the patient’s upper body is severely burned? | Popliteal The popliteal artery, behind the popliteal space in the lower extremity, can be used to assess blood pressure if the upper extremities are injured and cannot be used. |
| Which adult patient’s blood pressure reading would the nurse realize is unexpected? | 96/64 to 118/74 A 20 to 30 mm Hg change (either upward or downward) in either the systolic or diastolic reading when compared to an earlier reading is an unexpected finding, even though the individual readings are within the expected range. |
| Which actions would the nurse take when manually measuring the patient’s brachial blood pressure? | Deflate cuff at a rate of 2 mm Hg/second. Inflate cuff 30 mm Hg above the previous systolic reading. Position cuff 2.5 cm (1 inch) above the antecubital fossa. |
| Which patient cue would the nurse identify as relevant for blood pressure? | Reports blurred vision |
| Which information would the nurse share with a team member about the pathophysiology of hypertension? | Overstimulation of angiotensin and aldosterone causes the blood pressure to increase. Overstimulation of angiotensin and aldosterone causes the blood pressure to increase from neurohormonal dysfunction, leading to hypertension. |
| Which hypothesis would the nurse select for a patient with a blood pressure of 130/70 who when sitting up becomes dizzy and the blood pressure is 108/60? | Postural hypotension The patient has orthostatic, or postural, hypotension since this event of hypotension occurred when moving from a supine to a sitting position. |
| Which actions would the nurse take for a patient with low blood pressure from decreased peripheral vascular resistance? | Administer prescribed intravenous (IV) fluids. Administer prescribed oxygen. Position supine with legs elevated. |
| Which factor would the nurse consider is likely causing hypertension in an older adult female who is 5’4”, weighs 100 lbs (45.4 kg), drinks an occasional glass of red wine before bed, and limits salt in her diet? | Age The patient is an older adult, which increases the chance for hypertension. |
| Which finding would alert the nurse that a patient with a blood pressure of 80/40 is improving? | Skin becomes warm and dry. The patient has hypotension (80/40); if the skin becomes warm and dry, the patient is improving because the skin is not cool and clammy. |
| Which expected outcome would the nurse develop for a patient suffering with acute pain? | Patient will report a pain level of less than 3/10 within 45 minutes of receiving pain medication. This is an appropriate patient outcome because it provides reasonable outcome criteria within a reasonable amount of time. |
| Which cues would a nurse closely monitor to determine a patient’s pain level who is intubated and can have nothing by mouth? | pulse, blood pressure, restlessness |
| Which nonpharmacologic interventions would the nurse utilize to alleviate a patient’s immediate postoperative pain? | restrict visitors, close door, provide quite dim lit environment |
| Which action would the nurse likely take for a patient with a hip fracture who has advanced dementia, does not answer appropriately, and is disoriented? | Closely monitor the patient’s vital signs, as well as level of agitation, irritation, and restlessness. |
| Which pain assessment tool would the nurse use when assessing a young school-age patient who has a broken arm after falling off the jungle gym? | Wong-Baker FACES The popular pediatric FACES scale was originally created to help young children describe their pain. This is the most appropriate pain assessment tool for a pediatric patient. |
| Which patients would the nurse offer to massage the leg? | Has a leg with muscle spasms, Has a strained leg with tightness, , Has a sore leg with muscle tension |
| Which hypothesis would the nurse select for a postoperative patient who has increasing abdominal pain, a blood pressure of 142/92, and pulse of 110? | Acute Pain Increasing abdominal pain postoperatively, elevated blood pressure, and pulse rate indicate Acute Pain. |
| Which question would the nurse ask to determine the severity of the patient’s back pain? | On a scale of 0 to 10 with 10 being the worst pain in your life, how would you rate the pain? This question determines severity by asking the patient to rank the pain. |
| Which factors would decrease an anxious patient’s pain when fatigue is present and the patient’s partner rubs the painful area and talks about events happening at home? | emotional support, distraction, rubbing the painful area |
| Which classification would the nurse document the patient is experiencing when reporting the pain at a 7/10? | Moderate Moderate pain is ranked as 4 to 7. |
| Which question would be the most important for the nurse to ask when a postoperative patient says, “I’m hurting”? | Where is your pain? If the patient has had surgery, the nurse would not automatically assume the pain is around the incision. The nurse would follow up with “Where are you hurting?” because the patient may be having a headache and not incisional pain. |
| Which response would the nurse make to a patient who says, “I can’t go to sleep”? | “Is something bothering you or are you hurting?” |
| Which findings would alert the nurse the patient with an acute pain rating of 7/10 is declining? | States the pain is severe., Pulse increases. |
| Which information to help decrease the pain would the nurse share with a postoperative abdominal patient who states that it is hard to move because the incision hurts? | each the patient about splinting. Splinting (supporting the painful area with a pillow or blanket) will help decrease the pain when moving. |
| At which site would the nurse assess the patient’s apical pulse? | Left fifth and sixth intercostal space Assessment of the apical pulse requires use of a stethoscope and is best heard between the left fifth and sixth intercostal spaces, over the midclavicular line. |
| Which actions would the nurse take for a patient who develops tachycardia with dizziness and lightheadedness from hypovolemia? | Offer noncaffeinated beverages., Administer fluid replacement. , Monitor potassium and calcium levels. |
| Which action would the nurse take after obtaining a patient’s regular radial pulse rate of 45 in 30 seconds? | Document the appropriate heart rate. The nurse would document the appropriate heart rate (45 × 2 = 90) because the patient’s pulse is regular. |
| Which factors would the nurse consider for an elevated heart rate in a 78-year-old patient who had surgery 1 day prior and currently has a temperature of 102°F (38.9°C) and the nurse is having a difficult time obtaining a blood pressure? | Pain, Fever, a drop in blood pressure |
| Which action would the nurse take to obtain a patient’s apical pulse? | Count “lub-dub” as one beat. “Lub-dub” counts as one beat because one apical heartbeat has two sounds. |
| Which short-term outcome would the nurse develop for a patient experiencing a decreased heart rate? | Patient will exhibit pulse rate within expected range after 12 hours of beginning prescribed interventions. This is an expected outcome because it is measurable, specific, attainable, and realistic, and has a timeline that is short term. |
| Which pulse site would the nurse check when an infant appears lifeless? | Brachial The brachial pulse in the arm is the best choice as it is easily accessible on an infant. |
| Which information would the nurse share about a Holter monitor with a patient who is suffering from arrhythmias and has fainting spells? | This test utilizes a portable device attached to the chest by electrodes. A Holter monitor utilizes a portable device attached to the chest by electrodes. It measures and records the heart’s electrical activity continually. |
| Which conditions would prompt the nurse to consider a hypothesis of Bradycardia? | Hypothermia, Beta blocker administration, ncreased intracranial pressure |
| Which cues would the nurse assess for in an adult patient with bradycardia? | Sluggish, Lethargic, confused |
| Which finding would the nurse observe in an adult patient with Bradycardia who is improving? | Reflexes increase. Reflexes increasing indicates the patient is improving because slowed reflexes are a cue for Bradycardia. |
| Which actions would the nurse take for a patient who has Impaired Cardiac Function caused by overhydration and edema? | elevate legs at rest, check peripheral pulses, balance periods of rest and exercise, assess heart sounds |
| Which actions would the nurse take for a patient with tachycardia and atrial fibrillation whose pulse continues to increase? | Notify health care provider., Assist with electrical cardioversion., Transfer to intensive care unit., Suggest a consult with a cardiologist. |
| Which statement from the nurse indicates a correct interpretation of a higher temperature at 1830 when compared to the temperature at 1600? | “This is a typical response based on circadian rhythms.” Body temperature is affected by the circadian rhythm, so, for most people, their temperature is lowest around 3:00 a.m. (0300) and highest around 6:00 p.m. (1800). |
| Which patient would the nurse monitor closely for alterations in temperature control? | One who was admitted to the hospital after experiencing a cerebrovascular accident (stroke) |
| Which cues would the nurse likely observe in a patient who has a temperature of 92°F (33.3°C)? | drowniness, pale cool skin, decreased urinary output |
| Which action would the nurse take immediately after assessing a patient’s temperature to determine whether the patient has heat exhaustion or heatstroke? | Touch the patient’s skin. The nurse would touch the patient’s skin because heatstroke causes hot, dry skin (a key finding), whereas heat exhaustion causes hot, wet skin. |
| Which interventions would the nurse select for a patient with hypothermia who was rescued from drowning in a freezing river? | Administer prescribed warmed intravenous fluids, Apply several layers of warmed blankets., Wrap warm, dry towels around the patient’s head. |
| Which action by the nurse supports the hypothesis of Hypothermia when the patient presents with decreased respirations, cool skin, and low body temperature? | Take the patient’s blood pressure, which shows hypotension. Taking the patient’s blood pressure is an important step in supporting a hypothesis of Hypothermia, and hypotension is a cue that supports this condition. |
| Which statement from the nurse indicates appropriate clinical judgment in choosing a temperature assessment site? | Because the patient has a low white blood cell count, I will not take a rectal temperature.” |
| Which actions would the nurse take for a patient who has a fever? | lower room temp, decrease stress level, review culture and sensitivity reports |
| Which instruction will the nurse give the parent who asks how much aspirin should be given to a 3-year-old with a viral infection? | Do not give the medication.” The nurse would share this information because aspirin is not given to a 3-year-old with a viral infection; this can lead to Reye syndrome. |
| Which outcome would the nurse develop for a patient who is afebrile? | Patient’s temperature will be within the expected range until discharge. Because the patient is afebrile (no fever or temperature alterations), the nurse would maintain the temperature level within expected ranges until discharge. |
| Which cues alert the nurse a patient with hypothermia is improving? | temp increase, urinary output increases, |
| Which cues alert the nurse that a patient with hyperthermia is declining? | temp increase, heart rate increase, dizziness |
| Which action would the nurse take when measuring the tympanic temperature of a 5-year-old? | Pull the pinna up and back. For patients 4 years to adult, the pinna is pulled up and back to straighten the ear canal for a tympanic reading. |
| Which action would the nurse take when the unlicensed assistive personnel (UAP) reports an adult patient has a 99.5°F (37.5°C) temperature? | Recognize this is an expected finding. Although this is a high finding, it is an expected reading (99.5°F [37.5°C]) for a temperature. |
| Which instruction would the nurse share with a male patient who calls the clinic and tells the nurse that over a 24-hour period he has taken two extra strength acetaminophen tablets (1000 mg) every 4 hours for a fever? | This is too much acetaminophen. The nurse would share this information because the patient is exceeding the maximum dose (4 grams/day). |
Created by:
RachelKleinKatz1