GNRS 555 Exam 1 Questions with Correct Answers

GNRS 555 Exam 1 Questions with Correct Answers The certified nursing assistant (CNA) provides you with change-of-shift vitals on your patients. Which patient should you see FIRST? A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation (O2) 89% B.54 year-old woman admitted after surgery for fractured arm, blood pressure (BP) 160/86 mmHg, heart rate (HR) 72 C.63 year-old male with venous ulcers from diabetes temp 37.3C, HR 84 D.77 year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62 mmHg - Answer-A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation (O2) 89% What are the normal vital sign ranges for an adult? - Answer-BP: 120/80, RR: 12-20, Pulse: 60-100, Temp: 36-38C, SpO2: 95%+ When do you measure vital signs? - Answer--When assessing a patient during home care visits -In a clinic setting before a health care provider examines the patient and after any invasive procedures -In a hospital on a routine schedule according to the health care provider's order or hospital standards of practice -Before, during, and after a surgical procedure or invasive diagnostic/treatment procedure -Before, during, and after a transfusion of any type of blood product -Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions -When a patient's general physical condition changes (e.g., loss of consciousness or increased intensity of pain) -Before, during, and after nursing interventions influencing a vital sign (e.g., before a patient previously on bed rest ambulates or before a patient performs range-of-motion exercises) -When a patient reports nonspecific symptoms of physical distress (e.g., feeling "funny" or "different") What are factors that cause a change in body temp? - Answer-Age, exercise, hormonal level, environment/stress, circadian rhythm, temperature alterations You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup, but appears to be in no apparent distress. The nurse's most appropriate advice would be to do what? A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the patient to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature. - Answer-D. Wait 30 minutes and take an oral temperature. Where are the pulse sites? - Answer-Temporal, carotid, brachial, radial, ulnar, apical, femoral, popliteal, tibial, dorsal pedis Discuss physiological changes associated with fever. - Answer-Vasodilation, sweating, inhibition of heat production. Hypothalamus raises set point of internal temp and body produces/conserves heat. Chills, shivers, and feeling cold as body goes to new set point. Increased heart and respiratory rates