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12
| Question | Answer |
|---|---|
| A nurse is caring for a client with subnormal temperature. Which actions should the nurse perform to provide heat to the client's internal organs? | provide warm fluids |
| A nurse is caring for a client who has a lack of appetite. What is most likely to influence a client's core body temperature? | Proteins |
| A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature? | great surface area relative to mass and very high metabolic rate |
| The nurse notes that a client's temperature has increased from 102° F (38.9° C) to 103.6 ° F (39.8° C). Which is the most appropriate action for the nurse to take in this situation? | consult the physician and give antipyretics to the client |
| A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites corresponds most closely to the client's core body temperature! | ear |
| nurse has been asked to record a clients body temperature every hour, using a digital thermometer. After recording the temperature, the nurse has to clean the thermometer. Which measure should the nurse follow to clean the thermometer/ | wipe with isopropyl alcohol |
| nurse is assessing a client's body temperature. The nurse could obtain an accurate body temperature at the oral site for a client: | with a nasogastric tube in situ |
| A nurse is caring for a client with low body temperature. Which of these thermometers should be the nurse's first choice to measure the client's body temperature? | tvmDaniC |
| When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these nurse document as the character of the client's pulse? | thready pulse |
| A nurse is assessing the apical heart rate of a healthy person. In order to hear the heartbeats loud and clear, where should the nurse place the stethoscope? | slightly below the left nipple |
| A nurse needs to measure the blood pressure of a client with an electronic manometer. Which advantage does an electronic manometer provide over an aneroid manometer or mercury manometer? | accurate for practitioners with hearing loss |
| A nurse is assessing a client's vital signs at a health care facility. The nurse observes that the client is sweating profusely. What area of the brain causes a client to sweat? | hypothalamus |
| A nurse has assessed a client's blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mmHg and a diastolic blood pressure of 71 mmHg. The svstolic blood pressure: | represents peak pressure in the client's arteries. |
| A nurse has responded to a client's call light and found the client gasping and saying, "I can't get my breath." The nurse applied supplementary oxygen and repositioned the client. When documenting this event, the nurse should note that the client was: | dyspnea. |
| The nurse is performing client education with a 58-year-old client who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control their blood pressure! | reduce sodium intake |
| A client has an axillary temperature of 102.6 F (39.2° C). Which clinical manifestations would the nurse anticipate? Select all that apply. | A. respiratory rate 30/min B. headache E. red or flushed skin |
| A client presents to the Emergency Department with a temperature of 100.6F (38.1° C) and BP of 108/60 mmHg. What intervention does the nurse anticipate providing? | B. oral fluids |
| A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs? | Immediately |
| The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? | ask the client to demonstrate self-blood pressure assessment |
| The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body. | applying a blanket |
| 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 |
| 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 B. encourage slow movement from the bed to the E. encourage the client to use the call light prior to getting out of bed F. encourage the use of the call light for help to the bathroom |
| The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action? | ask the client to make a fist after cuff inflation |
| When assessing an adult client's pulse at 125 beats/min, which step would the nurse take first to determine intervention'? | Determine de cause |
| nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? | The radial pulse is difficult to obtain. |
| nurse received the following information about clients during shift report. Which client would the nurse assess first? | C. An adult client with a respiratory rate 26 breaths/min who slept in an upright position during the night. |
| A parent of a 9-year-old child states to the nurse, "I have not noticed any fever yet but my child describes feeling achy and not well." Which phase of the fever does the nurse identify the child may be experiencing? | Prodnormal |
| The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client? | C. The heart rate is within normal limits due to the exercise regimen the client is following. |
Created by:
Claudiavahd