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3100 EXAM 2 REVIEW.
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Exam of 36 pages for the course BUSMHR 3100 at BUSMHR 3100 (3100 EXAM 2 REVIEW.)
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3100 EXAM 2 REVIEWC
Individual vital signs are not as important as the trends. For instance, a patient may
have a blood pressure higher than "normal" that is normal for the patient. Trends give
more useful information than a single reading. Documentation is important, but the
nurse needs to do more. If the readings are significantly abnormal, the provider should
be notified. The nurse may retake the vital signs if he/she is not confident of the first set
of measurements, but should not wait for time to pass. - ANS-A nurse notes a patient
has abnormal vital signs. What action by the nurse is best?
A. Document the findings.
B. Notify the provider.
C. Compare with prior readings.
D. Retake the vital signs in 15 minutes.
D
The nurse uses clinical judgment to determine how often the patient's vital signs should
be checked when there is a change in patient condition. The nurse should plan to
assess vital signs more often in this patient. Since this is a significant change, the nurse
should not wait another hour even though this is what the provider prescribed. It is not
necessary for another nurse to double-check the vital signs. Documentation needs to
occur, but the priority is to plan to take the vitals more often. - ANS-A patient returned
from a procedure and has vital sign measurements ordered every hour. The
patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg.
What priority action by the nurse is most appropriate?
A. Take the vital signs again in another hour.
B. Document the findings in the patient's chart.
C. Have another nurse recheck the vital signs.
D. Plan to take the vital signs more often.
B
A temperature of 98.4 °F is normal. "Afebrile" means having a normal temperature. The
other readings are not related to this term. - ANS-A nurse is told in the hand-off report
that a patient is afebrile. What assessment finding correlates with this statement?
,A. Blood pressure 152/98 mm Hg
B. Temperature 98.4 °F (36.8 °C)
C. Apical pulse 82 beats/min
D. Respirations 16 breaths/min
B
Conduction is the transfer of heat through direct contact with another object, such as an
ice pack. A cooling fan would help lower temperature by convection. Spraying the
patient with a mist of water would lead to evaporative cooling. Turning the temperature
down is an example of radiation. - ANS-A nurse is caring for a patient who has an
elevated temperature. The nurse plans to help the patient regain a normal temperature
through conduction. What technique does the nurse use?
A. Placing a cooling fan in the patient's room
B. Putting ice packs in the patient's axillae
C. Spraying the patient with a fine mist of water
D. Turning the temperature down in the room
B
Oral temperatures will be inaccurate if the patient has been drinking or eating hot or
cold foods. The nurse instructs the patient not to continue drinking the coffee and
returns in 30 minutes to take the temperature. Drinking room temperature water will not
"even out" the patient's mouth temperature. The rectal route is not preferred by patients
and should not be used in this situation. The nurse needs a temperature and so should
not document that it was not obtained. - ANS-A nurse is going to take an oral
temperature on a patient who has just consumed a cup of
coffee. What action by the nurse is best?
A. Have the patient drink room temperature water.
B. Return in 30 minutes to take the patient's temperature.
C. Take the patient's temperature rectally instead.
D. Document that temperature is unable to be obtained.
B
For an adult, the correct procedure for taking a tympanic temperature includes pulling
the pinna of the patient's ear up and back. Children's pinnae are pulled down and back.
,Washing hands and explaining the procedure are appropriate. - ANS-A nurse observes
a student taking an adult patient's tympanic temperature. What action by the student
requires the nurse to intervene?
A. Student washes hands prior to patient contact.
B. Student pulls the pinna of the patient's ear down and back.
C. Student explains the procedure to the patient.
D. Student pulls the pinna of the patient's ear up and back.
A
Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or
fluid volume alterations. The nurse should assess the patient thoroughly for possible
causative factors. Since the pulse is regular, there is no reason to take an apical pulse.
The findings should be documented, but the nurse needs to do more. The provider may
or may not need to be notified, depending on the outcome of the nurse's assessment. -
ANS-A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular.
What action by the nurse is best?
A. Assess the patient for causes of tachycardia.
B. Take an apical heart rate and compare the two.
C. Document the findings in the patient's chart.
D. Notify the patient's health care provider.
B
The dorsalis pedis pulse is palpated on the top of the foot. The other assessment
locations and pulses are correct. - ANS-The student nurse is assessing a patient's
pulse. What action by the student requires the nurse to intervene?
A. Assessing apical pulse between the fifth and sixth intercostal spaces
B. Assessing the dorsalis pedis pulse by palpating behind the patient's knee
C. Assessing the radial pulse on the patient's wrist
D. Assessing the brachial pulse on the patient's inner elbow
A
A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume
overload, or overhydration. The nurse should assess for this situation. The other actions
, are not necessary. - ANS-The nurse assesses a patient's pulse and finds it hard to
obliterate with palpation. What action by the nurse is the most appropriate?
A. Assess the patient for fluid volume overload.
B. Assess the patient for fluid volume deficit.
C. Assess the patient's apical heart rate.
D. Assess the patient's pulse deficit.
C
The carotid arteries are the main supply route of blood to the brain. Compressing both
sides of the carotid arteries at the same time can lead to ischemia. The other actions
are appropriate. - ANS-The nursing faculty member is observing a student taking a
patient's carotid pulse. What action by the student requires intervention by the faculty
member?
A. Counts pulse for 30 seconds and multiplies by two.
B. Performs hand hygiene prior to patient contact.
C. Compares pulses in both carotid arteries at the same time.
D. Assesses pulse on one side then assesses the other side.
C
Orthopnea is difficulty breathing in positions other than sitting up. To assist the patient
who has orthopnea, the nurse keeps the head of the bed elevated to ease breathing. -
ANS-A nurse is caring for a patient who has orthopnea. What action by the nurse is
most appropriate?
A. Encourage deep breathing and coughing.
B. Medicate the patient for pain as needed.
C. Keep the head of the bed elevated
D. Monitor the length of time the patient doesn't breathe.
B
A patient who is hypothermic may not have good circulation to the extremities. The
nurse should assess the patient's circulation, and if it is poor to the extremities, choose
another spot at which to measure the oxygen saturation. Moving the probe to another
finger or removing nail polish will not help if the problem is poor circulation. The nurse
should document appropriately but needs to do more than just charting that the reading
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