NUFT 204 Exam #1 Questions With
Complete Solutions
Fundamentals of Nursing (Communication, Documentation, Patient Safety, Hygiene, Vital Signs, Asepsis Technique + Infection Control)
define temperature: correct answer: difference between heat produced & heat lost
define pulse: correct answer: palpable bounding of blood flow
_______ represents the minimum amount of pressure exerted on
the arteries correct answer: diastolic pressure
core temperature measurement sites (6) correct answer: - rectum
- tympanic membrane
- temporal artery
- pulmonary artery
- esophagus
- urinary bladder
acceptable oral temperature range of an adult: correct answer: 36 to 38 ºC (96.8 to 100.4 ºF)
_______ temperatures are usually 0.5 ºC higher than oral and tympanic temperatures correct answer: rectal where should an oral probe be placed? correct answer: posterior
sublingual pocket
use this temperature site ______ for clients who are 4 years of age or older correct answer: oral
how far should an anal probe be inserted? correct answer: 1 to 1.5 inches (for an adult)
safety measures to consider when taking temperature rectally (3): correct answer: - do not use for patients with diarrhea
- do not use for patients on bleeding precautions - do not use for patients with rectal disorders
a ______ measurement of temperature is generally most accurate correct answer: rectal
physical process of measuring tympanic temperature in an adult:
correct answer: pull the ear up and back
physical process of measuring tympanic temperature in a child younger than 3: correct answer: pull the ear down and back
fever is usually not harmful unless it exceeds ______ correct answer: 102.2 ºF (39 ºC)
how would you manage fever in adults? correct answer: provide
antipyretics (aspirin, acetaminophen, ibuprofen) how should fever NOT be managed in children and adolescents with viral illness? why? correct answer: do not give aspirin; risk
of Reye syndrome
hypothermia is a body temperature less than________ correct answer: 35ºC (95.2 ºF)
define pulse deficit: correct answer: difference between the apical and radial pulse rates
what is the procedure for irregular pulsation? correct answer: count for a full minute and compare the result to the apical pulse
rate
when would you use the apical pulse site (4)? correct answer: when assessing:
- infants
- rapid rates (faster than 100/min)
- irregular rhythms
- prior to the administration of cardiac medications
proper stethoscope placement: correct answer: fifth intercostal space at the left midclavicular line
accurate assessment of respiration involves observing 3 things: correct answer: - rate
- depth
- rhythm
respiration: the expected reference range for adults (per ATI) correct answer: 12 to 20 breaths/min
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