Hallmark ISB BSN 206
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Which of the following patients would require follow-up? | show 🗑
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| Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? | show 🗑
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| show | The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
The type of temperature required.
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| Which of the following situations may affect a patient's vital signs? (Select all that apply.) | show 🗑
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| show | To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. To provide a set of vital signs to use for comparison during and after surgery.
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| show | Assess the patient s blood pressure.
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| show | Elderly nursing home resident.
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| Which person would be expected to have the lowest body temperature? | show 🗑
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| show | "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
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| For which patient would a tympanic thermometer be the preferred thermometer to use? | show 🗑
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| Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) | show 🗑
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| show | Administer an antipyretic to the patient as ordered. Remove the patient's blankets.
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| Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) | show 🗑
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| Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) | show 🗑
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| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | show 🗑
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| show | Temporal artery
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| The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) | show 🗑
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| Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) | show 🗑
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| Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should initially do which of the following? | show 🗑
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| show | 60 to 100 beats per minute.
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| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | show 🗑
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| show | A patient returning from the operating room. A patient who received morphine for pain.
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| The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) | show 🗑
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| What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) | show 🗑
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| show | Having an addiction problem with amphetamines/cocaine Walking 1 mile briskly. Feeling anxious when taking a test.
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| When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse’s best action? | show 🗑
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| How can the nurse best obtain an accurate measurement of a patient’s respiratory rate? | show 🗑
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| The nurse is validating the NAP’s skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | show 🗑
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| The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | show 🗑
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| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | show 🗑
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| show | A patient with a deep vein thrombosis (blood clot, usually in the lower extremities).
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| show | Assess the BP in the other arm.
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| It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? | show 🗑
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| show | In the right arm
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| show | Take the patient's BP manually using a sphygmomanometer.
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| show | Assess the patient, including the pulse oximetry reading.
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| show | A patient with a continuous pulse oximetry reading of 84%.
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| A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? | show 🗑
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| show | Reassess the patient’s pulse oximetry.
Place the patient in the high-Fowler's position.
Assess the patient's respiratory and cardiac status.
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| show | Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading.
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| An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without havin | show 🗑
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| show | Explain the use of the call light.
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| show | An adult with a respiratory rate of 10 breaths per minute.
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| Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? | show 🗑
|
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| show | The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
The type of temperature required.
🗑
|
||||
| Which of the following situations may affect a patient's vital signs? (Select all that apply.) | show 🗑
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| The nurse will take the patient's vital signs preoperatively and record them as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) | show 🗑
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| The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? | show 🗑
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| show | Elderly nursing home resident.
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| show | An 80-year-old who walked half a mile.
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| show | "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
🗑
|
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| For which patient would a tympanic thermometer be the preferred thermometer to use? | show 🗑
|
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| Which of the following patients would require frequent assessment of their temperature? (Select all that apply.) | show 🗑
|
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| The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) | show 🗑
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| show | The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use.
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| show | Drinking a cold glass of water.
Participation in physical therapy exercises.
Room temperature.
Infection.
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| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | show 🗑
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| A newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? | show 🗑
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| show | A radial pulse on a patient with a 1200 mL fluid restriction.
The temporal pulse of a child.
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| show | A patient with peripheral vascular disease. The patient who was just informed of a diagnosis of cancer. A patient who is receiving bolus IV fluids.
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| show | Auscultate the apical pulse for quality and rate.
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| What is the normal pulse range for an adult? | show 🗑
|
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| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | show 🗑
|
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| In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) | show 🗑
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| show | The NAP is pressing down too hard on the patient’s radial site. The NAP is assessing for a pulse on the ulnar side of the wrist.
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| show | Count the respiratory rate again for a full 60 seconds (1 minute). Assess physiologic factors that may be causing the patient to breathe so fast.
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| show | Having an addiction problem with amphetamines/cocaine Walking 1 mile briskly. Feeling anxious when taking a test.
🗑
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| show | Move the patient's arm over their chest and feel the rise and fall of the chest.
🗑
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| show | Continue to act as though taking the patient’s pulse while discretely observing the rise and fall of the patient’s chest.
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| show | When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two
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| The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | show 🗑
|
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| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | show 🗑
|
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| For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? | show 🗑
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| show | Assess the BP in the other arm.
🗑
|
||||
| It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? | show 🗑
|
||||
| show | In the right arm
🗑
|
||||
| show | Take the patient's BP manually using a sphygmomanometer.
🗑
|
||||
| show | Assess the patient, including the pulse oximetry reading.
🗑
|
||||
| show | A patient with a continuous pulse oximetry reading of 84%.
🗑
|
||||
| show | "I will turn the continuous pulse oximetry alarms off at night so you can sleep."
🗑
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| The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) | show 🗑
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| The patient has an order for SpO2 every 4 hours. Based on this information, what would be the nurse's best action? 01/25/17 0800 Unable to obtain pulse oximetry reading. Attempted X2 fingers of each hand. Patient’s fingers cool to touch. Patient states | show 🗑
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| An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without havin | show 🗑
|
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| A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply.) | show 🗑
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| Which of the following patients would require follow-up? | show 🗑
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| show | Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%
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|
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| show | The frequency for taking or monitoring the temperature.
What changes to report immediately to the nurse.
The type of temperature required.
🗑
|
||||
| show | Moving from lying to standing position. Pain rated as a 7 on 0-10 pain scale. Time of day.
🗑
|
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| show | To verify the patient is not experiencing any complications that may contraindicate surgery or require intervention. To provide a set of vital signs to use for comparison during and after surgery.
🗑
|
||||
| The NAP reports to the nurse a 65-year-old patient s blood pressure is 160/98. What is the appropriate initial response of the nurse? | show 🗑
|
||||
| show | Elderly nursing home resident.
🗑
|
||||
| Which person would be expected to have the lowest body temperature? | show 🗑
|
||||
| show | "Ask the patient not to eat, drink, or smoke for 20 minutes and then assess the patient's oral temperature."
🗑
|
||||
| For which patient would a tympanic thermometer be the preferred thermometer to use? | show 🗑
|
||||
| show | A patient receiving a blood transfusion for chronic anemia. An adult female in the recovery room following a hysterectomy. A young adult with a white blood count of 15,000/mm3.
🗑
|
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| The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) | show 🗑
|
||||
| show | The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use.
🗑
|
||||
| Identify the factors that may have an effect on an elderly patient's temperature: (Select all that apply.) | show 🗑
|
||||
| If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? | show 🗑
|
||||
| show | Temporal artery
🗑
|
||||
| The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) | show 🗑
|
||||
| show | A patient with peripheral vascular disease. The patient who was just informed of a diagnosis of cancer. A patient who is receiving bolus IV fluids.
🗑
|
||||
| show | Auscultate the apical pulse for quality and rate.
🗑
|
||||
| What is the normal pulse range for an adult? | show 🗑
|
||||
| The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. | show 🗑
|
||||
| In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) | show 🗑
|
||||
| The new NAP is unable to palpate a patient’s radial pulse. What could be a possible explanation for this difficulty? (Select all that apply.) | show 🗑
|
||||
| What is an appropriate nursing intervention for an adult patient with a respiratory rate of 30 breaths per minute? (Select all that apply.) | show 🗑
|
||||
| Which of the following may increase both rate and depth of respiration? (Select all that apply.) | show 🗑
|
||||
| show | Move the patient's arm over their chest and feel the rise and fall of the chest.
🗑
|
||||
| show | Continue to act as though taking the patient’s pulse while discretely observing the rise and fall of the patient’s chest.
🗑
|
||||
| The nurse is validating the NAP’s skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? | show 🗑
|
||||
| The nurse assesses the BP in both arms of a newly admitted patient. Why would the nurse do this? | show 🗑
|
||||
| Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? | show 🗑
|
||||
| show | A patient with a deep vein thrombosis (blood clot, usually in the lower extremities).
🗑
|
||||
| The student nurse is unsure of the BP measurement. What should the student nurse do first? | show 🗑
|
||||
| It is 7 a.m. and the nurse takes the vital signs of a postoperative patient and finds his blood pressure is elevated. Which of the following could explain the cause for this alteration in BP? | show 🗑
|
||||
| show | In the right arm
🗑
|
||||
| show | Take the patient's BP manually using a sphygmomanometer.
🗑
|
||||
| show | Assess the patient, including the pulse oximetry reading.
🗑
|
||||
| show | A patient with a continuous pulse oximetry reading of 84%.
🗑
|
||||
| show | "I will turn the continuous pulse oximetry alarms off at night so you can sleep."
🗑
|
||||
| The NAP tells the nurse the patient's pulse oximetry is 85% on room air. What nursing action(s) should the nurse take? (Select all that apply.) | show 🗑
|
||||
| show | Have the NAP use a different site, such as the ear lobe, to obtain the SpO2 reading.
🗑
|
||||
| show |
🗑
|
||||
| show | Explain the use of the call light.
🗑
|
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Created by:
mgtupou23