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Terms in this set (24)A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A Temperature: 37° C (98.6° F) B Oxygen saturation is an assessment of oxygen perfusion. Respiratory rate assesses ventilation, radial pulse and blood pressure assess the cardiovascular system, and temperature is an assessment of thermal regulation.
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% A SpO2 89% is a critical value and requires immediate attention. Other values require attention but are not life threatening. A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A Right antecubital and tympanic membrane A IV in right arm can be turned off while blood pressure is obtained. Blood pressure should not be measured on fractured extremities that have compromised circulation. Sequential stocking should remain on all the time while the patient is in bed to promote blood flow in lower right extremity. Tympanic membrane temperature is not affected by oxygen; the oxygen would need to be removed to take an oral temperature. Forehead laceration excludes temporal measurement. Rectal temperature is more invasive. The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? A 96/40 mm Hg C Deflating the cuff too slowly will result in a false-high diastolic blood pressure. As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? A Nail polish attracts microorganisms and contaminates the finger sensor. C The pigment in black nail polish affects light absorption and reflection. A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? A Usual range of circadian rhythm measurements C Temperature was elevated above acceptable range, returned to normal, and then elevated. A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? A Request that the nursing assistant repeat the pulse check C A radial pulse of 44 is a critical value and requires additional assessment by the nurse. Decreased peripheral pulse can indicate cardiac or vascular abnormality, which can be determined by apical pulse and pulse deficit assessment. Which patient is at highest risk for tachycardia? A A healthy basketball player during warmup exercises C Fever elevates metabolism by 10%, resulting in an increased heart rate to remove the heat produced. Hypothermia and beta blockers decrease heart rate. Healthy athletes have a lower heart rate as a result of conditioning. A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? A Direct the NAP to hold the thermometer in place with her gloved hand D A temporal artery temperature verifies the forehead temperature in back of the left ear, which is the side not affected by the altered blood flow related to the stroke. Holding the thermometer or switching locations will not help the patient close her mouth during temperature assessment. The patient's right side has vascular changes related to the stroke. The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her
gallbladder is flashing a blood pressure of 65/46 and alarming. What is the correct order for care activities? 4.1.3.2.5 First priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assessing the patient. Check the distal pulse to verify circulation to the extremity and then obtain manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms Which of the following patients are at most risk for tachypnea? (Select all that apply.) A Patient just admitted with four rib fractures ABE Patient with rib fractures is unlikely to breathe deeply and a large fetus restricts diaphragmatic movement, leading to decreased ventilatory volume. Pneumonia decreases gas exchange surface area. Tachypnea occurs to increase minute ventilation. Alcohol is a respiratory depressant. The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) A Notify the health care
provider immediately A F The systolic BP measurements are significantly different and may reflect the vascular and muscular changes caused by the stroke. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider; differences are not caused by medications; inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements. A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) A Cuff too small A E Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow inflation result in false low readings. A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) A Right arm BP: 118/72 B D E Irregular pulse and elevated respiratory rate are outside of expected values and require further assessment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history. When heat loss mechanisms of the body are unable to keep pace with excess heat production, the result is known as A Pyrexia. A Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever "breaks," the patient becomes afebrile.
The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient's _____ pulse. A Radial C The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to lower arm. The posterior tibial pulse is used to assess the status of circulation to the foot. The patient's blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of (Points : 1)
C The patient is admitted with shortness of breath and chest discomfort. Which of the following laboratory values
could account for the patient's symptoms? (Points : 1) A The concentration of hemoglobin reflects the patient's capacity to carry oxygen. Normal hemoglobin levels range from 10 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal. The incidence of hypertension is greater in which of the following? (Points : 1) B The nurse
is caring for an elderly patient and notes that his temperature is 96.8° F (36° C). She understands that this patient is (Points : 1) B The average body temperature of older adults is approximately 96.8° F (36° C). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, and reduced metabolism. The end result is lowered body temperature. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? (Points : 1) D Preparing the child for the blood pressure cuff's unusual sensation increases cooperation. Most children will understand the analogy of a "tight hug on your arm." Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An "Infant" cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful. Of the following patients, which one is the best candidate to have his temperature taken orally? (Points : 1) A An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients. The physician order reads "Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication and (Points : 1) C The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider. The nursing assistive person is taking vital signs and reports that a patient's blood pressure is abnormally low. The nurse should (Points : 1) C The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse. Sets with similar termsChapter 29 Vital Signs46 terms lshearburn18 Chapter 29: Vital Signs**46 terms KIS1114 Chapter 30: Vital signs81 terms futurenursesmeow Sets found in the same folderChapter 30: Vital Signs31 terms ravecookiez Chapter 24 (Communication)28 terms lace_lou 4 older adults44 terms kayley_klaus Chapter 30: Vital Signs47 terms itschvse Other sets by this creatorClinical Practice Chapter 40 boxes.14 terms urness212 Clinical Practice Chapter 30 Vital Signs boxes40 terms urness212 Clinical Practice Exam 1 Chapter 2918 terms urness212 Acceptable abbr., symbols, and dose designations34 terms urness212 Recommended textbook solutions
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Which pulse site would the nurse assess for circulation of blood to the foot quizlet?The dorsalis pedis artery is palpated along the top of the foot.
Which site would the nurse assess to determine the status of circulation to the hand select all that apply one some or all responses may be correct?The ulnar region is the site used to assess the status of circulation in the hand and also used to perform an Allen test.
Where would the nurse locate the pulse to Auscultate blood pressure?Brachial pulse
This pulse is commonly used when manually assessing blood pressure. The main site is at the brachial plexus, in line with the biceps tendon. The patient's arm should be extended, with the palm facing upwards.
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Which site would the nurse assess to determine the status of circulation to the lower leg quizlet?
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