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Fundamentals > chapter 20 > Flashcards

chapter 20 Flashcards

1
Q

If the body is overheating, it will compensate with:
A - Vasodilation
B - Vasoconstriction

A

A

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2
Q

Mr. Lu is admitted with an abdominal pain. His oral temperature is 100.4°F (38°C), pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are:
A - Normal
B- Abnormal

A

B

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3
Q

Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are:
A - Normal
B - Abnormal

A

A

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4
Q

Ms. Hernandez has a temperature of 102.5°F. Antipyretic medication is ordered for a temperature higher than 39°C. Can the nurse safely administer the medication?
A - Yes
B - No

A

A

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5
Q

When a patient’s temperature increases, the pulse rate also increases. This finding would be:
A - Normal
B- Abnormal

A

A

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6
Q

While palpating Ms. Smith’s pulse, you find a rate of 116 beats/min. This finding is considered _______.
A- Tachycardia
B - Bradycardia

A

A

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7
Q

While assessing Mr. Brown’s respiratory rate, you also observe that his chest expands fully on inspiration. His respiratory depth would be considered:
A - Shallow
B - Deep

A

B

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8
Q

At the beginning of a visit, the nurse assesses Mr. Broda’s blood pressure and finds it is 116/76 mm Hg. During the visit, Mr. Broda receives some disturbing news about a diagnostic test. If his blood pressure was reassessed at that time, you would expect it to:
A - Rise
B - Fall

A

A

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9
Q

Ms. Weakly presents to the emergency department with difficulty breathing. Her respiratory rate is 28 breaths/min and her pulse is 110 beats/min. Given the situation, this finding is:
A - Normal
B - Abnormal

A

A

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10
Q

When a patient’s blood pressure decreases, his pulse increases. This finding would be:
A - Normal
B - Abnormal

A

A

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11
Q

Which blood pressure Korotkoff sound represents the systolic reading?
A - 1st Sound
B - 5th Sound

A

A

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12
Q

What are the primary vital signs of the nursing assessment? Select all that apply.

A - Blood pressure
B - Pulse
C - Pulse oximetry
D - Respiratory rate
E - Temperature

A

A
B
D
E

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13
Q

While palpating Mrs. Wong’s pulse, you find a rate of 40 beats/min. This finding is _________.

A - Tachypnea
B - Tachycardia
C - Bradypnea
D - Bradycardia

A

D

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14
Q

The nurse performs a vital sign assessment and obtains the following results: Temperature, 101.3°F (38.5°C); pulse, 110 beats/min; respiratory rate, 28 breaths/minute; blood pressure, 107/66 mm Hg. Which findings are abnormal? Select all that apply.

A - Respiratory rate
B - Systolic blood pressure
C - Temperature
D - Diastolic blood pressure
E - Pulse

A

A
C
E

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15
Q

_____________ pressure is peak blood pressure against arterial walls.

A - Brachial
B - Mean
C - Systolic
D - Radial
E - Diastolic

A

C

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16
Q

What information is needed when assessing the respiratory vital signs? Select all that apply.

A - Rate
B - Depth
C - Rhythm
D - Effort
E - Quality

A

A
B
C
D

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17
Q

Which factors impact a client’s normal body temperature? Select all that apply.

A - Age
B - Gender
C - Exercise
D - Environment
E - Recent intake

A

A
B
C
D

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18
Q

Which physiological processes occur when the hypothalamus is stimulated due to a client being warm? Select all that apply.

A - Epinephrine release
B - Peripheral vasodilation
C - Perspiration
D - Piloerection
E - Shunting of blood away from the periphery

A

B
C

19
Q

Which disorder can cause an increase in the basal metabolic rate (BMR) and thus raises body temperature?

A - Hypertension
B - Hyperlipidemia
C - Hypothyroidism
D - Hyperthyroidism

A

D

20
Q

In which clients would the nurse find elevated pulse rates? Select all that apply.

A - A 3-month-old infant
B - A client with hypothyroidism
C - A client taking digoxin (Lanoxin)
D - A client with a temperature of 101.0°F
E - A client with chronic obstructive pulmonary disease (COPD)

A

A
D
E

21
Q

The nurse is assessing a client with congestive heart failure and notes 3+ bilateral pitting pedal edema. The nurse is unable to palpate the pedal pulses. What would be the best intervention?

A - Document that the pedal pulses cannot be obtained.
B - Ask another nurse to verify the lack of pedal pulses.
C - Obtain a portable Doppler and check for pedal pulses.
D - Notify the primary health-care provider of a lack of pedal pulses.

A

C

22
Q

The nurse is working at a health fair providing blood pressure and pulse screenings. The nurse finds a young adult client has an apical pulse of 44 bpm. What would be the nurse’s first action?

A - Call 911 and notify emergency medical services (EMS).
B - Have the client drink some water, then recheck the apical pulse.
C - Ask the client if he or she is an athlete or runs every day.
D - Instruct the client to make an appointment to see his or her health-care provider.

A

C

23
Q

Which gases are primarily exchanged during respiration? Select all that apply.

A - Oxygen
B - Chloride
C - Nitrogen
D - Hydrogen
E - Carbon dioxide

A

A
E

24
Q

Which factors affect respiration? Select all that apply.

A - Decreased serum potassium levels
B - Level of carbon dioxide tension in the blood
C - Changes in pressure within the thoracic cavity
D - Central chemoreceptors in the medulla and pons
E - Peripheral chemoreceptors located in the carotid and aortic bodies

A

B
D
E

25
Q

A client visits an urgent care center while on vacation in Colorado. The client reports difficulty breathing since arriving. Which factor most likely explains the client’s dyspnea?

A - The client is experiencing a sickle cell crisis.
B - The high altitudes prevent oxygen from binding to hemoglobin.
C - The client has consumed large amounts of caffeinated coffee.
D - The client has underlying chronic obstructive pulmonary disease (COPD).

A

B

26
Q

What should the nurse do when obtaining a client’s orthostatic blood pressure (BP)?

A - Take the standing BP first.
B - Perform these readings prior to the client eating.
C - Wait 1 to 3 minutes in between each reading.
D - Document the lowest BP reading.

A

C

27
Q

Which is the best term for the nurse to include in his or her assessment documentation to note that a client is unable to lie flat without becoming short of breath?

A - Wheezes
B - Crackles
C - Dyspnea
D - Orthopnea

A

D

28
Q

A nurse has asked the unlicensed assistant personnel (UAP) to take vital signs on six clients. Which traditional measurements do vital signs include?

A - Pulse, respiratory rate, and temperature
B - Temperature, pulse, respirations, and blood pressure
C - Blood pressure, pulse, and temperature
D - Respirations, pulse, and temperature

A

B

29
Q

At what times should a client’s vital signs be measured and documented? Select all that apply.

A - On admission to a hospital or clinic visit
B - At the end of a shift
C - After certain medications have been administered
D - Whenever the client’s condition changes
E - Before and after surgery or certain procedures
F - At discharge

A

A
C
D

30
Q

In addition to the four major vital signs, the Joint Commission added a fifth vital sign. What is the fifth vital sign?

A - Oxygen saturation
B - Smoking status
C - Pain
D - Emotional distress

A

C

31
Q

A nurse is auscultating lung sounds on a client with asthma. The nurse would expect to hear which abnormal lung sounds in this client?

A - Low-pitched, continuous gurgling sounds caused by secretions in the large airways
B - High-pitched, continuous musical sounds, usually heard on expiration, which are caused by narrowing of the airways
C - A piercing, high-pitched sound that is caused by an obstructed airway and is most common in infants
D - Discontinuous popping sounds usually heard on inspiration and caused by fluid in the alveoli

A

B

32
Q

A nurse is learning about the processes of heat exchange between the body and the environment. What is this process that accounts for almost 50% of body heat loss called?

A - Convection
B - Radiation
C - Evaporation
D - Conduction

A

B

33
Q

A client has a respiratory rate of 8 breaths per minute. What is this rate called?

A - Apnea
B - Hypoxia
C - Tachypnea
D - Bradypnea

A

D

34
Q

A UAP has been assigned to take vital signs on four clients. Which temperature should be reported immediately to the nurse?

A - An oral temperature of 96.5°F for a client who is 88 years old
B - A rectal temperature of 99.9°F for a client who is 26 years old
C - An axillary temperature of 98.1°F for a client who is 30 years old
D - An oral temperature of 104.9°F for a client who is 40 years old

A

D

35
Q

A client with peripheral vascular disease has weak pedal pulses and the right foot is cool and pale. Which nursing diagnosis has the highest priority?

A - Ineffective tissue perfusion
B - Risk for impaired skin integrity
C - Risk for decreased cardiac output
D - Risk for deficient fluid volume

A

A

36
Q

A nurse is calculating the pulse pressure for a client who has a blood pressure of 150/80. What is the pulse pressure?

A - 230 mm Hg
B - 70 mm Hg
C - 1.875 mm Hg
D - 140 mm Hg

A

B

37
Q

When taking a manual blood pressure, the nurse listens for Korotkoff sounds. What numbers of Korotkoff sounds produce the systolic and diastolic numbers?

A - First and third
B - First and fourth
C - First and fifth
D - First and second

A

C

38
Q

What is the correct technique for palpating the carotid pulses?

A - Quickly palpate each carotid pulse so as to not make the client nervous.
B - Have the client hold his or her breath during palpation.
C - Gently palpate both carotid pulses at the same time.
D - Gently palpate one carotid pulse at a time.

A

D

39
Q

Pulse oximetry is a noninvasive method to assess a client’s oxygen level in what part of the blood?

A - Hematocrit
B - Platelets
C - White blood cells
D - Hemoglobin

A

D

40
Q

A nurse can delegate assessment of vital signs to a UAP for which clients? Select all that apply.

A - Client who is 1 hour post-appendectomy
B - Client who will be discharged to home the next day
C - Client who is 4 hours post laparoscopic cholecystectomy
D - Client with diverticulitis and taking prednisone
E - Client who has a pain level of 9 on a scale of 0 to 10

A

B
C
D

41
Q

Which are modifiable risk factors for preventing hypertension? Select all that apply.

A - Age
B - Smoking
C - Salt and alcohol intake
D - Sex
E - Ethnicity
F - Stress

A

B
C
F

42
Q

A nurse is reviewing the blood pressure log for a 57-year-old African American client. The average blood pressure for this client is 156/88. Which stage of blood pressure is this?

A - Normal
B - Prehypertension
C - Stage 1 hypertension
D - Stage 2 high blood pressure

A

D

43
Q

A home care nurse is teaching a client and his wife about taking digoxin. What is the most important teaching intervention?

A - Call the primary care provider if the pulse is less than 60.
B - Call the primary care provider if the client has difficulty voiding.
C - Call the primary care provider if the client loses his or her appetite.
D - Call the primary care provider if the client develops constipation.

A

A

44
Q

A nurse has received shift reports on several clients. Which client should the nurse see first?

A - A client with heart failure with a respiratory rate of 42 breaths per minute
B - A newly admitted client with fine wheezes in the upper lobes
C - A client with diabetes who has a pulse of 68
D - A client being discharged in one hour

A

A

Fundamentals (7 decks)

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