Ch 30: Review Questions & Rationales Flashcards
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?
- Temperature: 37° C (98.6° F)
- Radial pulse: 112
- Respiratory rate: 24
- Oxygen saturation: 96%
- Blood pressure: 134/78
Answer: 4.
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 practical nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
- 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
- 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72
- 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84
- 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
Answer: 1.
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?
- Right antecubital and tympanic membrane
- Right popliteal and rectal
- Left antecubital and oral
- Left popliteal and temporal artery
Answer: 1.
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?
- 96/40 mm Hg
- 110/66 mm Hg
- 130/90 mm Hg
- 156/82 mm Hg
Answer: 3.
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?
- Nail polish attracts microorganisms and contaminates the finger sensor.
- Nail polish increases oxygen saturation.
- Nail polish interferes with sensor function.
- Nail polish creates excessive heat in sensor probe.
Answer: 3.
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?
- Usual range of circadian rhythm measurements
- Sustained fever pattern
- Intermittent fever pattern
- Resolving fever pattern
Answer: 3.
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?
- Request that the nursing assistant repeat the pulse check
- Call for a stat electrocardiogram (ECG)
- Assess the patient’s apical pulse and evidence of a pulse deficit
- Prepare to administer cardiac-stimulating medications
Answer: 3.
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 healthy basketball player during warmup exercises
- A patient admitted with hypothermia
- A patient with a fever of 39.4° C (103° F)
- A 90-year-old male taking beta blockers
Answer: 3.
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.
Which of the following patients are at most risk for tachypnea? (Select all that apply.)
- Patient just admitted with four rib fractures
- Woman who is 9 months’ pregnant
- Adult who has consumed alcoholic beverages
- Adolescent waking from sleep
- Three-pack–per-day smoker with pneumonia
Answer: 1, 2, 5.
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.
Which number marks the location where you would auscultate the point of maximal impulse (PMI)?
- 1
- 2
- 3
- 4
- 5
- 6
Answer: 5.
This is the spot where you would auscultate the PMI.
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 531swallow 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?
- Direct the NAP to hold the thermometer in place with her gloved hand
- Direct the NAP to switch the thermometer probe to the left sublingual pocket
- Direct the NAP to obtain a right tympanic temperature
- Direct the NAP to use a temporal artery thermometer from right to left
Answer: 4.
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) 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.)
- Notify the health care provider immediately
- Repeat the measurements on both arms using a stethoscope
- Ask the patient if she has taken her blood pressure medications recently
- Obtain blood pressure measurements on lower extremities
- Verify that the correct cuff size was used during the measurements
- Review the patient’s record for her baseline vital signs
- Compare right and left radial pulses for strength
Answer: 2, 6.
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.
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. Place your care activities in priority order.
- Press the start button of the electronic blood pressure machine to obtain a new reading.
- Obtain a manual blood pressure with a stethoscope.
- Check the patient’s pulse distal to the blood pressure cuff.
- Assess the patient’s mental status.
- Remind the patient not to bend her arm with the blood pressure cuff.
Answer: 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.
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.)
- Cuff too small
- Arm positioned above heart level
- Slow inflation of the cuff by the machine
- Patient did not remove his long-sleeved shirt
- Insufficient time between measurements
Answers: 1, 5.
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.)
- Right arm BP: 118/72
- Radial pulse rate: 72 and irregular
- Temporal temperature: 37.4° C (99.3° F)
- Respiratory rate: 28
- Oxygen saturation: 99%
Answer: 2, 4, 5.
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.
