The nurse is caring for an older adult patient with poor dietary intake and decreased mobility.
Which action is least effective in diminishing the risk of pressure injuries?
Offer the patient nutritional supplements high in protein and iron.
Offer the patient water before each meal.
Sit...
N117 Exam 1 (Unit 1 - 7A) Questions &
Answers
The nurse is caring for an older adult patient with poor dietary intake and decreased
mobility.
Which action is least effective in diminishing the risk of pressure injuries?
Offer the patient nutritional supplements high in protein and iron.
Offer the patient water before each meal.
Sit with the patient during mealtimes to encourage eating.
Assess the patient's ability to swallow. - ANSWERSOffer the patient water before each
meal.
Which of the following patients would require follow-up?
A) A child with a respiratory rate of 24 breaths per minute.
B) An adolescent with a respiratory rate of 16 breaths per minute.
C) An adult with a respiratory rate of 10 breaths per minute.
D) A newborn with a respiratory rate of 50 breaths per minute. - ANSWERSC
Which of the following vital signs recorded for an older adult would be considered
acceptable (within normal limits)?
A) Temp 96.8° F, P-60, R-18, BP 160/90, O2 sat 93%.
B) Temp 97.0° F, P-60, R-16, BP 116/78, O2 sat 95%.
C) Temp 98.6 °F, P-56, R-20, BP 120/80, O2 sat 91%.
D) Temp 98.0 °F, P-76, R-22, BP 110/70, O2 sat 88%. - ANSWERSB
A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which
information should be provided to the NAP delegated to take her temperature? (Select
all that apply.)
A) The patient's age.
B) The type of temperature required.
C) The patient's diagnosis.
D) The frequency for taking or monitoring the temperature.
E) What changes to report immediately to you, the physician, or their delegate. -
ANSWERSB D E
Which of the following situations may affect a patient's vital signs? (Select all that
apply.)
A) Time of day.
,B) Occupation.
C) Moving from lying to standing position.
D) Pain rated as a 7 on 1-10 pain scale.
E) Isolation precautions. - ANSWERSA C D
You are supposed to take your patient's vital signs preoperatively and record them on
the patient's record as part of the patient's preparation for surgery. Why is it necessary
to take vital signs preoperatively? (Select all that apply.)
A) To see if the patient is "feeling funny."
B) To provide a set of vital signs to use for comparison during and after surgery.
C) To make sure the patient is not experiencing any complications such as a high fever
that may contraindicate surgery or require intervention at this time.
D) To provide the patient with reassurance that he or she is being cared for by a
competent staff. - ANSWERSB C
Who would you expect to have the lowest body temperature?
A) A 16-year-old who ran 1 mile.
B) An 80-year-old who walked half a mile.
C) A toddler who is febrile.
D) A child playing softball. - ANSWERSB
The NAP is preparing to measure a patient's vital signs. The patient reports having
eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best
response?
A) "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the
patient's oral temperature."
B) "Since the soup was not hot, go ahead and take the patient's temperature."
C) "Change to the red thermometer probe and take the patient's temperature rectally."
D) "Take the patient's temperature using the axillary route and when you record the
reading, add 1°F." - ANSWERSA
For which patient would a tympanic thermometer be the preferred thermometer to use?
A) A marathon runner who developed weakness during the race.
B) A newborn in the intensive care unit who requires continuous temperature
monitoring.
C) A child who had tubes surgically placed in the ears.
D) A tachypneic patient who is receiving oxygen by nasal cannula. - ANSWERSD
Which of the following patients would you expect to have to monitor their temperature
more frequently? (Select all that apply.)
A) A patient receiving a blood transfusion for chronic anemia.
B) An elderly patient who needs assistance with feeding and dressing.
C) A 43-year-old female who has undergone a hysterectomy.
D) A child who is small for his age.
E) A 19-year-old with a white blood count of 15,000. - ANSWERSA C E
,The NAP reports that the patient's temperature is 39° C. Which of the following are
appropriate nursing actions? (Select all that apply.)
A) Place the patient's feet in a tub of cool water with ice.
B) Apply a hyperthermia blanket as ordered.
C) Remove the patient's blankets.
D) Limit the patient's fluid intake.
E) Administer an antipyretic to the patient as ordered. - ANSWERSC E
Which of the following actions, if made by the NAP, would require intervention and
further instruction by the nurse? (Select all that apply.)
A) The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth
after applying a probe cover.
B) The NAP wipes the single-use chemical dot thermometer and places it back in the
patient's drawer for future use.
C) The NAP waits until a tone sounds to read the tympanic thermometer.
D) The NAP uses a blue-tipped electronic probe for assessing a patient's axillary
temperature.
E) The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic
thermometer. - ANSWERSA B
Identify the factors that may have an effect on an 82-year-old patient's temperature:
(Select all that apply.)
A) Drinking a cold glass of water.
B) Participation in strenuous physical therapy exercises.
C) Infection.
D) Room temperature.
E) Patient's body weight. - ANSWERSA B C D
If a 52-year-old patient has a normal temperature, what range should the patient's
temperature fall within?
A) 37° C to 39° C
B) 96.8° F to 100.4° F
C) 96.8° F to 98.6° F
D) 35° C to 36° C - ANSWERSB
Your 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?
A) Temporal artery
B) Tympanic
C) Chemical dot
D) Rectal electronic - ANSWERSA
Which of the following would be appropriate to delegate the task of pulse assessment?
(Select all that apply.)
A) An apical pulse of a patient who is going to receive digoxin (Lanoxin).
, B) A radial pulse on a patient with a 1200 mL fluid restriction.
C) A radial pulse of a patient in the emergency room with chest pain.
D) A femoral pulse following a lower leg amputation.
E) The temporal pulse of a child. - ANSWERSB E
Which of the following patients would you suspect would be at risk for having an
alteration in peripheral pulse? (Select all that apply.)
A) a 76-year-old with diabetes who is otherwise healthy.
B) A patient who was just informed of a diagnosis of cancer.
C) A patient with peripheral vascular disease.
D) A patient who is receiving bolus IV fluids.
E) A patient with Alzheimer's disease. - ANSWERSB C D
Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, you
should consider:
A) Checking the carotid pulse.
B) Using a stethoscope and assessing the quality of the apical pulse as well as the rate.
C) Counting the pulse again for 30 seconds and multiplying the results by two.
D) Checking the radial pulse on the opposite side. - ANSWERSB
What is the normal pulse range for an adult?
A) 120 to 160 beats per minute.
B) 90 to 140 beats per minute.
C) 60 to 100 beats per minute.
D) 50 to 80 beats per minute. - ANSWERSC
You should routinely auscultate the apical pulse with the bell side of the stethoscope.
A) True.
B) False. - ANSWERSB
n which of the following patients would you expect to find a decrease in pulse rate?
(Select all that apply.)
A) A newborn.
B) A patient returning from OR after having a hip replacement.
C) A patient who received morphine for severe cancer pain.
D) A student who is getting ready to take a final exam.
E) A patient who had a bleeding episode. - ANSWERSB C
How can you best obtain an accurate measurement of a patient's respiratory rate?
A) Inform the patient that you are monitoring his or her respirations.
B) Assess the respirations while the patient is talking.
C) Auscultate the lung sounds, asking the patient to take a deep breath in through the
nose and exhale slowly through the mouth.
D) Continue to act as though you are taking the patient's pulse while discretely
observing the rise and fall of the patient's chest. - ANSWERSD
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